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Knowledge Network in Rural and Remote Dementia Care
Healthcare Delivery Across the Continuum for Rural and Remote Seniors with Dementia
9th Annual Summit
October 25th & 26th, 2016
Scientifi c Poster Session
Tuesday October 25th, 2016Scientific Poster Program
7:00 PM – 9:30 pm at the Western Development Museum (Butler Byers Hall)
Poster Presenter Authors & Poster Titles Page
Alzheimer Society Staff
Alzheimer Society Programs and Services Staff
The Alzheimer Society of Saskatchewan’s Support Groups:Empowering people to live well with dementia
4
Camille Branger Branger C, O’Connell ME
Finding a Balance: Investigating Current Conceptualization and Measurement of Positive Aspects of Caring for a Loved one withDementia
5
Julia Brassolotto Brassolotto, J
Intersections of Formal and Informal Care in Rural Alberta’s Long-Term Care Facilities
6
Allison Cammer Cammer A, Whiting S, Morgan D,
Care Aide Perceptions of Best Nutritional Care Practices for Residentswith Dementia in Urban and Rural Long-Term Care
7
Alexander Crizzle Sanford S, Naglie G, Tuokko H, Crizzle A, Gélinas I, Belchior P, Rapoport M
Facilitating Decision-Making about Driving Cessation for People with Dementia: Stakeholder Perspectives
8
Tracy Danylyshen-Laycock
Danylyshen-Laycock T, Morgan D, Stewart N
The Impact of Leadership on Sustainability of a Dementia SpecificTraining Program in Long-Term Care
9
Ben Gould Gould B, Enright J, O’Connell ME, Morgan D
Reliable Change (RCI) on Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in a Dementia Sample
10
Ben Gould Gould B, O’Connell ME, Bourassa C, Jacklin K, Carter J
Exploring Mi’kmaq Communities’ Mental Wellness Needs: Understanding the Appropriate Approaches to Improving Quality of Life
11
Kaeli Knudsen Knudsen K, Heistad R, Nyarko J, Greer J, Carvalho CE, Mousseau D
Non-canonical amyloid transport by the serotonin transporter mod-5 in C. elegans
12
Julie Kosteniuk Kosteniuk J, Morgan D, Acan Osman B, Quail J, O’Connell ME, Kirk A, Stewart N, Osman M
CCNA Team 20 Rural: A retrospective matched case control cohort study of health service use over a 10-year period by individuals with incident dementia in Saskatchewan, Canada
13
Julie Kosteniuk Kosteniuk J, Morgan D, O’Connell ME, Kirk A, Stewart N
A Baseline Study of the Dementia Care Landscape in Sun Country Health Region: A Report by the Rural Dementia Action Research Team
14
Poster Presenter Authors & Poster Titles Page
Wendy Lucyshyn Lucyshyn W, O’Connell ME, Dal Bello-Haas V
Minds in Motion® 15
Leslie Malloy-Weir
Malloy-Weir L, Morgan D, Kosteniuk J, Michael J, Bracken J, McDavid J
Formative Evaluation of the Outreach Component of the Alzheimer Society of Saskatchewan’s First Link™ Program
16
Debra Morgan Morgan D, Kosteniuk J, Seitz D, O’Connell ME, Kirk A, Stewart N, Holroyd-Leduc JCCNA Team 20 Rural: Developing rural dementia care best practicesin primary health care teams: A community-based approach
17
Jennifer Nyarko Nyarko J, Quartey M, Penninton P, Baker G, Mousseau D
Are targets of depression-related drugs useful diagnostics for Alzheimer Disease?
18
Megan O’Connell Burton R, O’Connell ME
Exploring interest and goals for videoconferencing delivered cognitive rehabilitation with rural individuals with mild cognitive impairment or dementia
19
Megan O’Connell Enright J, O’Connell ME
Identity and Caregiver Burden in Dementia: An Evaluation of Telehealth Reminiscence for Informal Caregivers
20
Megan O’Connell O’Connell ME, Gould B, Scerbe A, Morgan D, Carter J, Bourassa C, Jacklin K, Warry W
Worries about Maintaining Independence of Rural/Remote Older Adults: Opportunities for Technology Development
21
Megan O’Connell O’Connell ME, Gould B, Scerbe A, Morgan D, Carter J, Bourassa C, Owl N, Jacklin K, Warry W
Unmet Needs of Rural/Remote Older Adults: Opportunities for Technology Development
22
Maa Quartey Quartey M, Nyarko J, Pennington P, Chaharyn BM, Maley J, Baker G, Mousseau D
Are all β-amyloid peptides bad? *A preliminary investigation* 23
Wendy Quinn Quinn W, Hammond Y, DeCoteau E
Geriatric Assessment Service (Proposal) 24
Mark Rapoport Chee J, Carr D, Herrmann N, Hawley C, Classen S, O’Neil D, Marottoli R, Mitchell S, Tant M, Charlton J, Dow J, Marshall S, Molnar F, Ayotte D, Lanctot K, McFadden R, Olsen K, Donaghy P, Taylor JP, Rapoport M
Driving With Dementia: A Collaborative International Knowledge Synthesis To Update Clinical Guidelines For Physicians
25
Mark Rapoport Rapoport M, Zucchero Sarracini C, Rozmovits L, Kiss A, Grigoriev I, Taylor R, Herrmann N, Mulsant BH, Cameron D, Frank C, Seitz D, Byszewski A, Tang-Wai D, Masellis M, Molnar F, Naglie G
A Driving in Dementia Decision Tool: Preliminary Analysis26
Poster Presenter Authors & Poster Titles Page
Andrea Scerbe Scerbe A, O’Connell ME
Assessment of Primary Health Care Learning Needs in a Rural Area 27
Susan Tupper Tupper S, Christopher GM, Juckes K, Baerg K,
Mapping a Pain Strategy for Saskatchewan: findings from stakeholder consultations
28
Susan Tupper Tupper SM, Bareham J, Danylyshen-Laycock T, Bergen A
Development of a brief education series for healthcare providers: Understanding, Assessing and Managing Pain in Older Adults
29
Jake Ursenbach Ursenbach J, O’Connell ME
Improving rural dementia diagnosis: Implementing remote specialist-to-PHC provider support
30
Jake Ursenbach Ursenbach J, Campeau S, Tariq S, Carlson HL, Coutts S, Barber PA
Predicting cognitive decline after TIA with diffusion tensor imaging and texture analysis of normal appearing white matter
31
Ryan Verity Verity R, Kirk A, Karunanayake C, Morgan D
The “Worried Well”: Characteristics of the Cognitively Normal Patient Presenting to a Rural and Remote Memory Clinic
32
4
Our
Sup
po
rt G
roup
mis
sio
n is
to
pro
vid
e p
eop
le w
ith
dem
enti
a,
thei
r fa
mily
mem
ber
s an
d f
rien
ds
wit
h a
safe
and
sup
po
rtiv
e en
viro
nmen
t w
here
the
y ar
e ab
le t
o d
evel
op
mea
ning
ful
conn
ecti
ons
, exp
erie
nce
a se
nse
of
bel
ong
ing
, gai
n un
der
stan
din
g
and
kno
wle
dg
e, a
nd b
e em
po
wer
ed t
o li
ve p
roac
tive
ly t
hro
ugho
ut
thei
r jo
urne
y w
ith
dem
enti
a.O
pp
ortu
niti
es f
or C
lient
s C
areg
iver
Sup
po
rt G
roup
For
thos
e ca
ring
for
som
eone
wit
h th
e d
isea
se –
sp
ouse
s, f
amily
or
frie
nds.
Co
ffee
Clu
bM
aint
aini
ng a
ful
fillin
g s
ocia
l life
is im
por
tant
for
peo
ple
livi
ng w
ith
dem
enti
a an
d t
heir
car
e p
artn
ers.
The
Alz
heim
er S
ocie
ty o
f Sa
skat
chew
an c
oord
inat
es
a nu
mb
er o
f C
offe
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lub
s th
at p
rovi
de
an o
pp
ortu
nity
to
soci
aliz
e, s
hare
ex
per
ienc
es, l
aug
h an
d e
njoy
the
com
pan
y of
oth
ers
who
und
erst
and
and
are
liv
ing
the
dem
enti
a ex
per
ienc
e.
Ear
ly S
tag
e Su
pp
ort
Gro
upTh
is g
roup
is o
nly
atte
nded
by
the
per
son
wit
h d
emen
tia
(PW
D).
This
ens
ures
th
at t
he P
WD
has
a p
lace
to
spea
k op
enly
ab
out
thei
r st
rug
gle
s w
ith
the
dis
ease
, em
pow
er t
hem
to
lear
n fr
om e
ach
othe
r an
d h
ave
fun
in a
sa
fe p
lace
.
Tele
heal
th S
po
usal
Sup
po
rt G
roup
sTh
ere
are
2 Te
lehe
alth
Sup
por
t G
roup
ser
ving
the
pro
vinc
e. T
he A
typ
ical
g
roup
is in
tend
ed f
or s
pou
ses
of p
eop
le w
ho h
ave
bee
n d
iag
nose
d w
ith
a fo
rm
of d
emen
tia
that
is u
ncom
mon
, dia
gno
sed
at
a yo
ung
er a
ge,
and
doe
s no
t p
rese
nt li
ke A
lzhe
imer
’s d
isea
se. T
he F
ront
otem
por
al g
roup
is s
pec
ifica
lly f
or
spou
ses
of t
hose
who
hav
e b
een
dia
gno
sed
wit
h Fr
onto
tem
por
al d
emen
tia
and
it
s va
rian
ts.
New
and
Uni
que
Op
por
tuni
ties
Car
egiv
er T
elep
hone
Sup
po
rt G
roup
Ther
e ar
e m
any
par
ts o
f Sa
skat
chew
an t
hat
do
not
have
Alz
heim
er
Soci
ety
Car
egiv
er S
upp
ort
Gro
up.
The
Car
egiv
er T
elep
hone
Sup
por
t G
roup
can
ass
ist
to fi
ll th
at v
oid
for
car
egiv
ers
livin
g in
the
se
und
erse
rved
are
as o
f th
e p
rovi
nce.
“I t
houg
ht t
hat
if I
faci
litat
ed t
his
gro
up, t
he f
amili
es w
oul
d a
lso
hel
p
me.
I am
so
tha
nkfu
l fo
r th
e w
ond
erfu
l ad
vice
I g
aine
d f
rom
man
y fa
mily
mem
ber
s o
ver
the
year
s. I
t he
lped
tre
men
do
usly
in le
arni
ng
how
to
car
e fo
r p
eop
le w
ith
dem
enti
a. T
hey
mak
e m
y d
ay e
very
day
!”
Trud
y at
tend
ed t
he fi
rst
form
al S
upp
ort
Gro
up F
acili
tato
r tr
aini
ng
and
is s
till
a V
olu
ntee
r Fa
cilit
ato
r to
day
.
Pro
vid
ing
hel
p f
or
tod
ay
and
ho
pe
for
tom
orr
ow
for
peo
ple
aff
ecte
d
by
dem
enti
a
Lad
y o
f th
e P
rair
ies
The A
lzheim
er
So
ciety
of
Sas
katc
hew
an’s
Sup
po
rt G
roup
sE
mp
ow
eri
ng
peo
ple
to
live
well
wit
h d
em
enti
a
All
of o
ur v
olun
teer
fac
ilita
tors
re
ceiv
e tr
aini
ng a
nd o
ngoi
ng
pro
fess
iona
l dev
elop
men
t
Sup
por
ts m
ust
be
avai
lab
le in
a v
arie
ty o
f fo
rmat
s to
mee
t th
e d
iver
se n
eed
s of
th
e p
eop
le t
hat
the
Soci
ety
serv
es.
Gro
ups
offe
r p
eop
le w
ith
dem
enti
a an
d c
areg
iver
s to
ols
that
can
imp
rove
q
ualit
y of
life
and
enh
ance
the
ir a
bili
ty t
o co
pe
wit
h th
e ch
alle
nges
of
the
dis
ease
. Th
ese
gro
ups
pro
vid
e a
safe
env
ironm
ent
whe
re in
div
idua
ls c
an le
arn,
la
ugh
and
enc
oura
ge
each
oth
er t
hrou
gh
mut
ual u
nder
stan
din
g.
Youn
g O
nset
Tel
ehea
lth
Gro
upTh
is g
roup
ser
ves
ind
ivid
uals
dia
gno
sed
und
er t
he a
ge
of 6
5. T
hese
cl
ient
s ha
ve d
iver
se n
eed
s th
at d
iffer
fro
m t
hose
dia
gno
sed
in la
ter
life
incl
udin
g c
aree
r lo
ss, r
aisi
ng y
oung
fam
ilies
and
fina
ncia
l ins
ecur
ity.
D
ue t
o th
e re
lati
vely
sm
all n
umb
er o
f p
eop
le, t
his
is a
pro
vinc
ial g
roup
.
Sand
wic
h C
lub
Fo
r th
ose
who
are
car
ing
for
som
eone
wit
h A
lzhe
imer
’s d
isea
se o
r a
rela
ted
dem
enti
a an
d b
alan
cing
the
dem
and
s of
a f
amily
and
a c
aree
r.
Vol
unte
er O
pp
ortu
niti
es Su
pp
ort
Men
tor
Val
ueA
SOS
cont
inue
s to
rec
ruit
ind
ivid
uals
to
act
as f
acili
tato
rs in
co
mm
unit
ies
acro
ss t
he p
rovi
nce.
The
re a
re m
any
com
mun
itie
s th
at
coul
d b
enefi
t fr
om y
our
know
led
ge
and
exp
erie
nce.
The
ASO
S is
co
mm
itte
d t
o su
pp
orti
ng y
ou a
s th
e g
roup
is e
stab
lishe
d a
nd w
ill
cont
inue
to
men
tor
you
as t
he g
roup
gro
ws
and
dev
elop
s. T
here
are
d
iffer
ent
gro
ups
to m
eet
the
need
s of
the
com
mun
itie
s. A
sk o
ne o
f ou
r Pr
ogra
ms
and
Ser
vice
s st
aff
how
you
cou
ld b
ecom
e in
volv
ed.
Our
Sup
po
rt G
roup
s ar
e m
ade
po
ssib
le b
y th
e g
ener
ous
sup
po
rt o
f
Po
ster
co
ntri
but
ors
Alz
heim
er
Soci
ety
Pro
gra
ms
and
Ser
vice
s st
aff
5
Stud
y 1
INTR
OD
UCT
ION
Purp
ose
The
purp
ose
of th
e pr
opos
ed re
sear
ch is
to
gain
a b
ette
r und
erst
andi
ng o
f cur
rent
co
ncep
tual
izat
ions
and
mea
sure
men
t of
posi
tive
aspe
cts
of c
arin
g fo
r per
sons
with
de
men
tia.
Rat
iona
le•
Can
adia
n in
form
al c
areg
iver
s pr
ovid
e ca
re
with
a y
early
est
imat
ed v
alue
of $
26 b
illion
1
•C
areg
iver
rese
arch
pro
vide
s be
tter
unde
rsta
ndin
g of
the
care
give
r exp
erie
nce
and
info
rms
on in
terv
entio
ns a
imed
to
supp
ort a
nd s
usta
in c
areg
iver
s in
thei
r rol
e.
•Ex
tant
lite
ratu
re re
veal
s an
em
phas
is o
n ne
gativ
e as
pect
s of
car
egiv
ing
(i.e.
, ca
regi
ver b
urde
n an
d st
rain
), w
ith a
sm
alle
r nu
mbe
r of s
tudi
es in
vest
igat
ing
posi
tive
aspe
cts
(i.e.
, car
egiv
er s
atis
fact
ion
and
pers
onal
gai
n).
•By
syn
thes
izin
g ex
tant
lite
ratu
re o
n po
sitiv
e as
pect
s of
car
egiv
ing,
this
rese
arch
aim
s to
(1
)und
erst
and
how
pos
itive
asp
ects
of
care
givi
ng a
re c
omm
only
con
cept
ualiz
ed,
(2) h
ow th
ese
are
mea
sure
d, (3
) if/h
ow
posi
tive
aspe
cts
rela
te to
oth
er c
omm
only
m
easu
red
aspe
cts
of c
areg
ivin
g (e
.g.,
burd
en, w
ell-b
eing
, sev
erity
of d
emen
tia),
and
(4) i
dent
ifyw
hat i
s kn
own
and
wha
t is
mis
sing
.
Find
ing
a B
alan
ce: I
nves
tigat
ing
Cur
rent
Con
cept
ualiz
atio
n an
d M
easu
rem
ent o
f Pos
itive
Asp
ects
of C
arin
g fo
r a L
oved
one
with
D
emen
tiaC
. Bra
nger
B.S
c. (H
ons)
PhD
Stu
dent
Clin
ical
Psy
chol
ogy
,Sup
ervi
sor:
Dr.
Meg
an O
’Con
nell
Dep
artm
ent o
f Psy
chol
ogy,
Uni
vers
ity o
f Sas
katc
hew
an
1 H
olla
nder
, M. J
., Li
u, G
., &
Cha
ppel
l, N
. L. (
2009
). W
ho c
ares
and
how
muc
h? T
he im
pute
d ec
onom
ic c
ontri
butio
n to
the
Can
adia
n. h
ealth
care
sys
tem
of
mid
dle-
aged
and
old
er u
npai
d ca
regi
vers
pro
vidi
ng c
are
to th
e el
derly
. Hea
lthca
re Q
uarte
rly, 1
2(2)
, 42-
49.
2 St
atis
tics
Can
ada.
(201
1). P
ortra
it of
Fam
ilies
and
Liv
ing
Arr
ange
men
ts in
Can
ada:
Fam
ilies
, hou
seho
lds
and
mar
ital s
tatu
s,20
11 C
ensu
s of
Pop
ulat
ion.
St
atis
tics
Can
ada
Cat
alog
ue n
o. C
atal
ogue
no.
98-
312-
X201
1001
. Otta
wa.
Ver
sion
upd
ated
Sep
tem
ber 2
012.
Otta
wa.
ht
tp://
ww
w.st
atca
n.gc
.ca/
refe
renc
e/co
pyrig
ht-d
roit-
aute
ur-e
ng.h
tm(O
ctob
er, 1
8, 2
013)
3 H
abja
n, S
., Pr
ince
, H.,
& Ke
lly, M
. (20
12).
Car
egiv
ing
for e
lder
s in
firs
t nat
ions
com
mun
ities
: Soc
ial s
yste
m p
ersp
ectiv
e on
bar
riers
and
cha
lleng
es.
Can
adia
n Jo
urna
l on
agin
g, 3
1 (2
),20
9-22
2. d
oi:1
0.10
17/S
0714
9808
1200
013X
C. B
rang
er is
a p
roud
reci
pien
t of t
he A
lzhe
imer
’s S
ocie
ty D
octo
ral A
war
d.
Met
a-An
alys
isM
eta-
Synt
hesis
Synt
hesis
Met
hods
: Mix
ed M
eta
Met
hods
: Mix
ed M
eta
Synt
hesi
s Th
is u
niqu
e m
etho
d sy
nthe
size
s fin
ding
s fro
m a
met
a an
alys
is b
ased
on
quan
titat
ive
rese
arch
and
find
ings
from
a
met
a sy
nthe
sis
of q
ualit
ativ
e w
ork.
Base
d on
Qua
ntita
tive
rese
arch
th
is m
eta
anal
ysis
will
prov
ide
info
rmat
ion
on:
•C
urre
nt c
once
ptua
lizat
ions
of
posi
tive
aspe
cts
•To
ols
of m
easu
rem
ent
•Ef
fect
siz
es in
dica
ting
how
po
sitiv
e as
pect
s re
late
to o
ther
va
riabl
es
Base
d on
Qua
litat
ive
rese
arch
, th
is m
eta-
synt
hesi
s w
ill pr
ovid
e in
form
atio
n on
:•
Com
mon
aliti
es in
car
egiv
er
expe
rienc
e •
Sum
mar
izin
g an
d co
mbi
ning
qu
alita
tive
evid
ence
su
rroun
ding
pos
itive
asp
ects
of
car
egiv
ing.
Find
ings
from
the
met
a-sy
nthe
sis
info
rm o
n ef
fect
siz
es re
veal
ed b
y m
eta-
anal
ysis
. •
The
findi
ngs
from
this
stu
dy a
re e
xpec
ted
to e
xpan
d th
e cu
rrent
un
ders
tand
ing
of th
e po
sitiv
e as
pect
s of
car
egiv
ing
by s
ynth
esiz
ing
exta
nt
liter
atur
e fro
m b
oth
quan
titat
ive
and
qual
itativ
e di
rect
ions
,•
This
rese
arch
is e
xpec
ted
to g
ive
a cl
ear a
ccou
nt o
f how
the
posi
tive
aspe
cts
of c
areg
ivin
g ar
e cu
rrent
ly c
once
ptua
lized
,•
how
we
are
mea
surin
g th
ese
aspe
cts
•* w
hat m
ay b
e m
issi
ng fr
om c
urre
nt c
once
ptua
lizat
ion
and
mea
sure
s.•
Thes
e fin
ding
s w
ill in
dica
te im
porta
nt a
reas
for f
utur
e re
sear
ch.
Case
Stu
dy
*
By m
eans
of o
pen
ende
d in
terv
iew
w
ith tw
o Ab
orig
inal
car
egiv
ers,
this
st
udy
aim
s to
:•
Prov
ide
insi
ght i
nto
this
un
ders
tudi
ed p
opul
atio
n of
ca
regi
vers
. •
Prom
pt fu
ture
rese
arch
into
this
im
porta
nt a
nd g
row
ing
popu
latio
n.
Purp
ose
Prov
ide
insi
ght i
nto
expe
rienc
e of
impo
rtant
, gr
owin
g, a
nd u
nder
stud
ied
popu
latio
n of
ca
regi
vers
in C
anad
a.R
atio
nale
Prel
imin
arily
lite
ratu
re re
view
reve
als
rese
arch
on
Abor
igin
al c
areg
iver
s of
per
sons
w
ith d
emen
tia is
rem
arka
bly
scan
t.
•Th
e pr
eval
ence
of a
ge-re
late
d de
men
tia
cont
inue
s to
rise
in th
e fa
st g
row
ing
dem
ogra
phic
of A
borig
inal
sen
iors
2 .
•Av
aila
bilit
y of
car
egiv
ers
for A
borig
inal
se
nior
s w
ith d
emen
tia is
dec
reas
ing
as
dem
ogra
phic
s ch
ange
(you
th m
igra
ting
to
urba
n ce
ntre
s) a
nd c
omm
unity
vie
ws
and
valu
es c
hang
e3.
Met
hods
Thro
ugh
conn
ectio
ns w
ith th
e R
ural
and
R
emot
e M
emor
y C
linic
of S
aska
toon
, we
will
invi
te A
borig
inal
car
egiv
ers
to s
hare
with
us
abou
t the
ir ex
perie
nce
prov
idin
g ca
re.
•D
ata
will
be o
btai
ned
thro
ugh
open
end
ed
indi
vidu
al in
terv
iew
Stud
y 2
INTR
OD
UCT
ION
6
Inte
rsec
tion
s of
For
mal
and
Info
rmal
Car
e in
Rur
al A
lber
ta’s
Lo
ng-T
erm
Car
e Fa
cilit
ies
Dr. J
ulia
Bra
ssol
otto
. Fa
culty
of H
ealth
Sci
ence
s, U
nive
rsity
of L
ethb
ridge
. Alb
erta
Inno
vate
s -He
alth
Sol
utio
ns (A
IHS)
Res
earc
h Ch
air i
n He
alth
y Fu
ture
s and
Wel
l-bei
ng in
Rur
al S
ettin
gs
ABST
RACT
The
prop
osed
rese
arch
will
expl
ore
the
inte
rsec
tions
offo
rmal
and
info
rmal
care
for
olde
radu
ltsw
itha
focu
son
thos
ew
hopr
ovid
eca
re.L
ittle
atte
ntio
nha
sbe
enpa
idto
the
heal
than
dw
elln
ess
ofth
ose
who
perfo
rmca
rew
ork
for
olde
rad
ults
livin
gin
resid
entia
lca
refa
cilit
ies
inru
ral
Albe
rta.
Inlig
htof
Cana
da’s
agin
gpo
pula
tion,
chal
leng
esw
ithre
crui
ting
and
reta
inin
gru
raln
urse
s,an
dth
ere
stru
ctur
ing
ofth
eco
ntin
uing
care
syst
em,
the
chal
leng
esex
perie
nced
byru
ral
care
prov
ider
sar
eco
nsta
ntly
chan
ging
.
Inan
exte
nsio
nof
the
Prin
cipa
lIn
vest
igat
or’s
post
doct
oral
wor
k,th
ete
amw
illco
nduc
tca
sest
udie
sus
ing
criti
cale
thno
grap
hyan
ddo
cum
ent
anal
ysis
met
hods
inor
der
tobe
tter
unde
rsta
ndw
orki
ngco
nditi
ons
for
care
wor
kers
inru
ralA
lber
ta.T
here
sear
chte
amw
illco
nduc
tin
-dep
thin
terv
iew
sw
ithpa
idan
dun
paid
care
wor
kers
,pe
rfor
mpa
rtic
ipan
tob
serv
atio
nsin
the
faci
litie
s,an
dan
alyz
ere
late
ddo
cum
ents
.Sp
ecia
latt
entio
nw
illbe
paid
tom
atte
rsof
gend
er,r
ace,
soci
oeco
nom
icst
atus
,and
othe
rso
cial
loca
tions
and
the
way
sin
whi
chth
eyen
able
and/
orco
nstr
ain
care
wor
ker
expe
rienc
esin
this
rura
lcon
text
.The
team
will
also
expl
ore
the
orga
niza
tion
ofca
rew
ork
inth
ese
faci
litie
san
dth
ero
leof
the
long
-term
care
(LTC
)hom
ein
rura
lco
mm
uniti
es.
This
rese
arch
will
iden
tify
LTC
prio
rity
issue
sat
the
mac
ro(p
olic
y),m
eso
(hea
lthca
resy
stem
),an
dm
icro
(fam
ilyan
dco
mm
unity
)lev
elso
fcar
e.
BACK
GROU
ND
•In
the
1990
s,th
eAl
bert
a’s
cont
inui
ngca
resy
stem
was
dram
atic
ally
rest
ruct
ured
.W
ithsig
nific
ant
shift
sto
war
dsho
me
care
,ass
isted
livin
g,an
dag
ing-
in-p
lace
,the
publ
icLT
Cse
ctor
face
dsiz
eabl
esp
endi
ngcu
ts.
•M
uch
ofth
ere
sear
chon
elde
rcar
ein
Cana
dafo
cuse
son
urba
nse
ttin
gs.T
here
are
few
erLT
Cfa
cilit
ies
inru
ralr
egio
nsan
da
host
ofru
ral-s
peci
ficLT
Cre
late
diss
ues.
Litt
leis
know
nab
out
the
curr
ent
stat
eof
rura
lLTC
faci
litie
san
dth
ero
le(s
)of
thes
eho
mes
inth
eirc
omm
uniti
es.
•Th
eor
gani
zatio
nof
LTC
wor
kis
chan
ging
acro
ssCa
nada
,w
ithRN
sdo
ing
mor
ead
min
istra
tive
wor
kan
dun
regu
late
dw
orke
rspe
rform
ing
the
maj
ority
ofdi
rect
resid
entc
are
(Arm
stro
ng&
Bain
es,2
016)
.
•LT
Cfa
cilit
iesa
rela
rgel
yvi
ewed
and
fund
edas
sites
ofhe
alth
care
serv
ice
prov
ision
and
asla
stre
sort
sfo
rfa
mily
mem
bers
who
can
nolo
nger
care
for
rela
tives
atho
me.
This
pilo
tpr
ojec
t,an
dth
ela
rger
rese
arch
prog
ram
ofw
hich
itis
apa
rt,i
sde
signe
dto
expl
ore
the
notio
nof
“hom
e”in
rura
lLTC
faci
litie
s.Ac
cord
ing
toRa
mp
(199
9)ru
rali
nstit
utio
nssu
chas
hosp
itals
orsc
hool
sar
e“m
ore
than
just
‘faci
litie
s’in
afu
nctio
nals
ense
.The
yar
eal
socu
ltura
lsig
nsan
dsy
mbo
ls”(p
.6).
With
inth
epo
litic
alan
dec
onom
icco
ntex
tsof
seni
ors’
hous
ing
inru
ral
Albe
rta,
we
will
expl
ore
wha
titi
slik
eto
live
and
wor
kin
LTC.
OBJE
CTIV
ES1)
Build
ast
rong
and
colla
bora
tive
rese
arch
team
,inc
ludi
ngco
mm
unity
part
ners
and
know
ledg
eus
ers.
Esta
blish
afe
edba
cklo
opto
mee
tour
colle
ctiv
eco
mm
unic
atio
nne
eds.
2)Im
prov
eun
ders
tand
ing
ofth
ecu
rren
tsta
teof
LTC
hom
esin
rura
lAlb
erta
.
3)U
nder
stan
dth
eor
gani
zatio
nof
care
wor
kan
did
entif
yth
ene
eds
ofth
ose
prov
idin
gpa
idan
dun
paid
care
with
inth
ese
faci
litie
s.
4)Ga
inin
sight
into
the
role
sLTC
hom
espl
ayw
ithin
rura
lcom
mun
ities
5)Id
entif
ych
alle
nges
inca
repr
ovisi
onan
dge
nera
tepo
licy
and
prac
tice
reco
mm
enda
tions
6)Id
entif
ysu
cces
sst
orie
san
dde
velo
pa
know
ledg
eba
nkof
prom
ising
prac
tices
inru
ralL
TC.
7)Ex
plor
eop
port
uniti
esfo
rin
ter-
sect
oral
colla
bora
tion
and
inno
vativ
ew
ays
toad
dres
sLTC
resid
ents
’soc
iala
ndno
n-m
edic
alne
eds.
MET
HOD
S•
Case
stud
y(Y
in,2
009)
,wee
k-lo
ngsit
evi
sits
•Cr
itica
leth
nogr
aphy
(Tho
mas
,199
3),“
Ethn
ogra
phy
with
apo
litic
alpu
rpos
e”
•In
-dep
th,s
emis
truc
ture
din
terv
iew
sw
ithpa
idan
dun
paid
care
prov
ider
sin
LTC
hom
es(R
Ns,
LPN
s,ca
reai
des,
dire
ctor
sof
care
,man
agem
ent,
fam
ilym
embe
rs,
volu
ntee
rs,s
tude
nts,
paid
com
pani
ons)
.
•Fi
eld
site
obse
rvat
ions
invi
sitor
-frie
ndly
spac
es
•Do
cum
ent
anal
ysis
(Atk
inso
n&
Coffe
y,19
97)
oflo
gic
mod
els,
polic
ies,
faci
lity
regu
latio
nsan
dpr
actic
es,e
tc.
PROG
RESS
& D
EVEL
OPM
ENTS
•Sc
opin
gre
view
•Et
hics
appl
icat
ion
•Gr
anta
pplic
atio
n
•Kn
owle
dge-
shar
ing
wor
ksho
p
•Pi
lotc
ase
stud
y
•De
velo
ping
part
ners
hips
and
colla
bora
tions
7
Car
e A
ide
Perc
eptions
of
Bes
t N
utritiona
l Car
e Pr
actice
s fo
r R
esid
ents
with
Dem
entia
in U
rban
and
Rur
al L
ong
-Ter
m C
are
1,2 A
. Cam
mer
, 1 S. W
hiting
, 2 D. M
org
an.
1 Colle
ge o
f Ph
arm
acy
and N
utri
tion,
Uni
vers
ity
of
Sask
atch
ewan
, 2C
anad
ian
Cen
tre
for
Hea
lth
and S
afet
y in
Agr
icul
ture
, Uni
vers
ity
of
Sask
atch
ewan
Using
an
evid
ence
-bas
ed p
ract
ice
(EBP)
fra
mew
ork
, wha
t ar
e be
st n
utrition
care
pra
ctic
es for
LTC
res
iden
ts w
ith
dem
entia
from
the
per
spec
tive
of ca
re a
ides
?•
Gai
n ex
per
ient
ial k
now
ledge
of
stra
tegi
es u
sed t
o a
ccom
plis
h go
od n
utrition
care
•Bet
ter
under
stan
d t
he c
halle
nges
exp
erie
nced
by
care
aid
es in
pro
vidin
g nu
tritio
n ca
re f
or
residen
ts w
ith
dem
entia
•Exa
min
e diffe
renc
es b
etw
een
urba
n an
d r
ural
LT
C
•Q
ualit
ativ
e A
ppro
ach
–fo
cus
group
discu
ssio
ns
•Fo
ur L
TC
hom
es;
2 ru
ral an
d 2
urb
an
•A
gree
men
t to
par
tici
pat
e at
Reg
iona
l lev
el a
nd A
dm
inistr
ativ
e le
vel of
each
LT
C h
om
e
•R
QH
R M
ealtim
e M
anag
emen
t vi
deo
sho
wn
follo
wed
by
focu
s gr
oup
s
•Se
t of
guid
ing
ques
tions
with
pro
mpts
•Fr
amew
ork
Ana
lysis
(Rab
iee,
200
4)
Bac
kgro
und
Res
earc
h Q
uest
ion
and O
bjec
tive
s
Met
hods
Res
earc
h Fi
ndin
gs: T
hem
atic
Ana
lysis
•D
emen
tia
pre
sent
s div
erse
and
com
ple
x nu
tritio
n ca
re n
eeds
withi
n th
e LT
C c
ont
ext, w
ell r
ecogn
ized
by
care
aid
es.
•M
any
opport
unitie
s fo
r in
terv
ention
can
be iden
tified
fro
m t
hese
find
ings
. Enh
ance
d t
rain
ing,
gre
ater
coord
inat
ion
of
nutr
itio
n ca
re, su
pport
ive
super
vision,
and
adap
tive
men
toring
may
hel
p
to s
upport
car
e ai
des
in
per
form
ing
nutr
itio
n ca
re p
ract
ices
.
Implic
atio
ns f
or
Prac
tice
Ack
now
ledge
men
ts
Dem
entia
is r
ecogn
ized
as
a pub
lic h
ealth
priority
; w
orldw
ide
pre
vale
nce
of
dem
entia
is p
roje
cted
to d
oub
le t
o 6
5.7
mill
ion
by
2030
(W
HO
, 20
12).
Dem
entia
is t
he t
op c
hroni
c co
nditio
n pro
mpting
rel
oca
tion
to
long
-ter
m c
are
(LT
C) (A
DI, 2
013)
and
60%
of
Can
adia
n LT
C
residen
ts h
ave
a dia
gnosis
of
dem
entia
(CIH
I, 2
013)
.
Pers
ons
with
dem
entia
are
at h
ighe
r risk
for
mal
nutr
itio
n due
to b
oth
phy
siolo
gica
l and
beh
avio
ur c
hang
es. M
alnu
tritio
n ca
n ac
cele
rate
cogn
itiv
e dec
line,
incr
ease
risk
of
nega
tive
hea
lth
out
com
es (un
wan
ted w
eigh
t lo
ss o
r ga
in, m
uscl
e w
asting
, in
fect
ion,
poor
woun
d h
ealin
g, p
ress
ure
ulce
r fo
rmat
ion)
, an
d n
egat
ivel
y im
pac
t qu
ality
of
life.
LTC
sta
ff a
re r
espons
ible
for
dev
elopin
g an
d e
xecu
ting
res
iden
t nu
tritio
nal c
are
pla
ns, m
oni
toring
res
iden
ts’
food a
nd f
luid
in
take
, en
cour
agin
g in
dep
enden
ce a
nd p
rom
oting
soci
al w
ell-
bein
g as
it p
erta
ins
to e
atin
g an
d n
our
ishm
ent. T
he m
ajority
of
direc
t re
siden
t ca
re in
LTC
is
per
form
ed b
y ca
re a
ides
who
hav
e lim
ited
form
al t
rain
ing
in d
emen
tia
and n
utrition
care
(Pe
lletier
, 20
05).
Part
icip
ants
•Po
ster
adve
rtisin
g re
sear
ch p
roje
ct a
t ea
ch L
TC
hom
e•
Volu
ntar
y par
tici
pat
ion
dur
ing
sche
dul
ed w
ork
•
Info
rmed
cons
ent
pro
cess
•A
udio
rec
ord
ings
of
each
focu
s gr
oup
discu
ssio
n•
Des
crip
tive
fie
ld n
ote
s w
ritt
en a
fter
eac
h fo
cus
group
discu
ssio
n
Oper
atio
naliz
ing
Pers
on-
Cen
tere
d C
are
•C
om
ple
x th
eore
tica
l orien
tation
to c
are
•C
an b
e ch
alle
ngin
g to
det
erm
ine
whi
ch
pra
ctic
es r
espec
t PC
C a
t a
give
n tim
e•
Mul
tiple
inte
rpre
tations
Exp
erie
ntia
l Lea
rnin
g•
Tra
inin
g or
stud
ying
ver
sus
‘rea
l w
orld’
•U
nabl
e to
tea
ch e
very
beh
avio
r/sc
enar
io•
Shad
ow
ing
and m
ento
ring
to a
chie
ve
pro
fici
ency
and
conf
iden
ce
Bal
anci
ng R
esid
ents
’ C
are
Nee
ds
•W
ork
load
oft
en d
icta
tes
care
ava
ilabl
e•
Prio
rity
car
e ne
ed o
f a
give
n m
om
ent
a m
ovi
ng t
arge
t•
Rout
ine
or
sche
dul
e co
nflic
t w
ith
care
pla
n
Perc
eption
of
Nut
rition
Car
e•
Focu
sed o
n phy
sica
l and
mec
hani
stic
as
pec
ts o
f nu
tritio
n ca
re•
Less
att
ention
give
n to
psy
choso
cial
co
mpone
nts
of
nutr
itio
n ca
re
Com
pet
ing
Dem
ands
•Bet
wee
n dep
artm
ents
•
Am
ong
st s
taff
•M
any
residen
ts•
Num
erous
inte
ract
ions
Copin
g St
rate
gies
•A
lter
nate
str
ateg
ies
dev
eloped
to
com
pen
sate
for
lack
ing
hum
an r
esour
ces,
know
ledge
res
our
ces, o
r to
ols t
o f
acili
tate
nu
tritio
n ca
re
Impac
t of
Rur
al L
oca
tion
Am
oun
t of
Cho
ice
Ava
ilabl
e-
Acc
ess
to S
pec
ialis
t C
are
Support
-Em
plo
ymen
t C
halle
nges
-Pe
rsona
l Kno
wle
dge
of
Indiv
idua
l
Res
iden
ts/F
amili
es
+
Indep
enden
t T
roub
lesh
ooting
+/-
8
9
The
Impa
ct o
f Lea
ders
hip
on S
usta
inab
ility
of a
Dem
entia
Spe
cific
Tr
aini
ng P
rogr
am in
Lon
g-Te
rm C
are
Trac
y D
anyl
yshe
n-La
ycoc
k, P
hD. C
andi
date
, Hea
lth S
cien
ces
Col
lege
of M
edic
ine,
Uni
vers
ity o
f Sas
katc
hew
an, D
ebra
M
orga
n, R
N, P
hD.,
Col
lege
of M
edic
ine,
Uni
vers
ity o
f Sas
katc
hew
an, a
nd N
orm
a St
ewar
t, R
N, P
hD.,
Col
lege
of N
ursi
ng,
Uni
vers
ity o
f Sas
katc
hew
an
Intr
oduc
tion
The
Gen
tle P
ersu
asiv
e A
ppro
ache
s (G
PA) P
rogr
am
Met
hods
Dat
a A
naly
sis
Con
clus
ions
Dem
entia
can
cau
se m
emor
y lo
ss, p
erso
nalit
y ch
ange
s, an
d re
spon
sive
beh
avio
urs
(Tor
py,
Lynm
, & G
lass
, 200
8). E
xam
ples
of r
espo
nsiv
e be
havi
ours
incl
ude:
wan
derin
g, y
ellin
g, o
r hi
tting
. Res
pons
ive
beha
viou
rs a
re b
elie
ved
to b
e an
exp
ress
ion
of a
nee
d; a
n in
divi
dual
with
de
men
tia is
resp
ondi
ng to
som
ethi
ng in
thei
r en
viro
nmen
t tha
t is o
ut o
f the
ir co
ntro
l (Ta
leric
o &
Eva
ns, 2
000)
.
Car
e st
aff a
re th
e m
ost f
requ
ent r
ecip
ient
s of t
he
resp
onsi
ve b
ehav
iour
s (G
ates
, Fitz
wat
er, &
Su
ccop
, 200
3). S
taff
need
the
oppo
rtuni
ty to
de
velo
p sp
ecia
lized
skill
s whe
n ca
ring
for
indi
vidu
als w
ith re
spon
sive
beh
avio
urs.
A
sust
aina
ble
train
ing
prog
ram
is o
ne o
f the
way
s to
assi
st st
aff i
n m
anag
ing
resp
onsi
ve b
ehav
iour
s (E
aton
, 200
3).
The
GPA
pro
gram
is a
dem
entia
spec
ific
7.5
hour
ev
iden
ce-b
ased
edu
catio
n se
ssio
n de
sign
ed fo
r st
aff w
ho c
are
for o
lder
adu
lts w
ho d
ispl
ay
resp
onsi
ve b
ehav
iour
s. Th
e ov
eral
l goa
l of t
he
GPA
cur
ricul
um is
to e
duca
te st
aff o
n ho
w to
use
a
pers
on-c
entre
d, c
ompa
ssio
nate
, and
gen
tle
pers
uasi
ve a
ppro
ach
and
to re
spon
d re
spec
tfully
, w
ith c
onfid
ence
and
skill
, to
resp
onsi
ve
beha
viou
rs a
ssoc
iate
d w
ith d
emen
tia.
Two
stud
ies w
ere
cond
ucte
d si
mul
tane
ousl
y to
ex
amin
e th
e re
latio
nshi
p be
twee
n le
ader
ship
and
su
stai
nabi
lity.
Stud
y 1
(Ret
rosp
ectiv
e):
Des
ign:
cros
s-se
ctio
nal,
retro
spec
tive
qual
itativ
e re
sear
ch d
esig
n.Si
te se
lect
ion:
5ho
mes
wer
e pu
rpos
ivel
y sa
mpl
ed fr
om ru
ral L
TC h
omes
with
sim
ilar
num
ber o
f res
iden
ts a
nd w
here
GPA
had
bee
n im
plem
ente
d in
200
9.Pa
rtic
ipan
ts: a
dmin
istra
tors
, Dire
ctor
s of C
are,
M
anag
ers,
nurs
es (R
Ns,
RPN
s, LP
Ns,
Clin
ical
N
urse
Lea
ders
) and
NA
s.D
ata
colle
ctio
n:
•Se
mi-s
truct
ured
inte
rvie
ws (
n=14
); •
Focu
s gro
ups (
n=4)
.
Stud
y 2
(Pro
spec
tive)
:D
esig
n: p
rosp
ectiv
e lo
ngitu
dina
l, m
ulti-
site
, co
mpa
rativ
e ca
se st
udy
desi
gn.
Site
Sel
ectio
n: 2
hom
es w
ere
purp
osiv
ely
sam
pled
bas
ed o
n “c
ompa
rison
of d
iffer
ence
” de
sign
logi
c (F
itzge
rald
& D
opso
n, 2
009)
that
m
axim
ized
var
iatio
n on
org
aniz
atio
nal f
acto
rs
that
may
influ
ence
impl
emen
tatio
n an
d su
stai
nabi
lity
of th
e G
PA p
rogr
am:
•A
ffilia
te v
s ow
ned/
oper
ated
by
heal
th re
gion
; •
Man
agem
ent a
nd re
porti
ng st
ruct
ure;
•Po
sitio
n of
GPA
Coa
ch (e
.g. R
N v
s NA
); •
Pres
ence
/abs
ence
of C
linic
al N
urse
Lea
der;
•Si
mila
r num
ber o
f res
iden
ts.
Dat
a co
llect
ion:
•
Dire
ct o
bser
vatio
ns (1
4 m
onth
s);
•Sh
adow
ing
and
info
rmal
inte
rvie
ws (
6 m
onth
s);
•Se
mi-s
truct
ured
inte
rvie
ws w
ith st
aff i
n al
l de
partm
ents
(n=1
5);
•D
ocum
ent r
evie
ws (
i.e.,
nurs
ing
prog
ress
no
tes,
com
mun
icat
ion
logs
, inc
iden
t rep
orts
) be
ginn
ing
thre
e m
onth
s prio
r to
GPA
im
plem
enta
tion.
Res
earc
h Q
uest
ion
Wha
t is t
he ro
le o
f for
mal
lead
ersh
ip (i
.e.,
M
anag
er, D
irect
or o
f Car
e, a
nd A
dmin
istra
tor)
in
the
sust
aina
bilit
y of
the
GPA
pro
gram
with
in ru
ral
long
-term
car
e ho
mes
(LTC
)?
Stud
y 1
(Ret
rosp
ectiv
e):
Dat
a w
ere
anal
yzed
usi
ng a
qua
litat
ive,
indu
ctiv
e ap
proa
ch, u
sing
the
cons
tant
com
para
tive
met
hod
(Gla
ser &
Stra
us, 1
967,
Cha
rmaz
, 200
6).
Stud
y 2
(Pro
spec
tive)
:i.
With
in c
ase
anal
ysis
: ind
uctiv
e, g
roun
ded
appr
oach
, usi
ng th
e co
nsta
nt c
ompa
rativ
e m
etho
d to
ana
lyze
the
four
type
s of d
ata
from
ea
ch h
ome
ii.C
ross
cas
e an
alys
is:e
xam
ined
ove
rall
patte
rns
for s
imila
ritie
s and
diff
eren
ces a
cros
s the
2
hom
esO
vera
ll co
nclu
sion
s: a
n in
terp
retiv
e pa
ttern
-m
atch
ing
appr
oach
was
use
d to
com
pare
the
patte
rns o
f fin
ding
s bet
wee
n th
e tw
o st
udie
s.
Find
ings
A c
ontin
uum
of l
ow, m
ediu
m, a
nd h
igh
sust
aina
bilit
y ho
mes
em
erge
d in
the
retro
spec
tive
stud
y. D
ata
conf
irmed
a lo
w su
stai
nabi
lity
hom
e an
d a
high
sust
aina
bilit
y ho
me
in th
e pr
ospe
ctiv
e st
udy
and
supp
orte
d th
e re
latio
nshi
p be
twee
n le
ader
ship
and
sust
aina
bilit
y.
Lead
ers i
n th
e hi
gh su
stai
nabi
lity
hom
es d
ispl
ayed
a
grea
ter r
ange
of le
ader
ship
skill
s, w
ith m
ore
freq
uenc
yan
d in
tens
ityth
an le
ader
s in
the
low
an
d m
ediu
m su
stai
nabi
lity
hom
es.
Lead
ers i
n th
e hi
gh su
stai
nabi
lity
hom
es c
reat
ed a
cu
lture
whe
re p
erso
n-ce
ntre
d ca
re w
as th
e ph
iloso
phy
of c
are
with
in th
e ho
me.
Skill
s of t
he le
ader
s in
the
high
sust
aina
bilit
y ho
mes
incl
uded
: •
Com
mun
icat
ing
to st
aff t
hat G
PA is
an
expe
ctat
ion;
•K
eepi
ng st
aff a
ccou
ntab
le w
hen
they
did
not
pr
actic
e G
PA;
•W
orki
ng w
ith st
aff w
ho w
ere
“neg
ativ
e”
tow
ards
the
prog
ram
;•
Add
ress
ing
barr
iers
that
impa
cted
the
sust
aina
bilit
y of
the
GPA
pro
gram
.
Prio
r to
the
impl
emen
tatio
n of
the
GPA
pr
ogra
m, l
eade
rs sh
ould
ass
ess t
heir
orga
niza
tiona
l cul
ture
and
thei
r sta
ff m
embe
rs’
read
ines
s for
cha
nge.
It is
impo
rtant
for l
eade
rs to
1) a
ddre
ss a
ny
outs
tand
ing
barr
iers
to im
plem
enta
tion
and
wor
k w
ith in
divi
dual
s who
do
not s
uppo
rt pe
rson
-cen
tred
care
or t
he G
PA p
rogr
am, a
nd 2
) cr
eate
a c
ultu
re w
here
staf
f hav
e th
e fle
xibi
lity
and
reso
urce
s to
prac
tice
pers
on-c
entre
d ca
re.
It is
ben
efic
ial f
or le
ader
s to
be a
ppro
acha
ble,
vi
sibl
e, a
nd p
rovi
de fe
edba
ck o
n pe
rfor
man
ce
as w
ell a
s men
torin
g st
aff w
ho e
xhib
it
poor
/abu
sive
per
form
ance
.
10
Ea
ch o
f the
53 p
erso
ns
rece
ived
an
inte
rdis
cipl
inar
y di
agno
sis o
f de
men
tia
INT
RO
DU
CT
ION
Purp
ose
Ex
amin
ing
relia
ble
chan
ge a
nd m
inim
al c
linic
ally
im
porta
nt d
iffer
ence
s (M
CID
) in
RB
AN
S sc
ores
for
pers
ons w
ith d
emen
tia a
t a o
ne y
ear i
nter
val u
sing
D
uff’
s2pr
edet
erm
ined
regr
essi
on fo
rmul
as a
nd P
hilli
p’s6
anch
or-b
ased
cut
-off
scor
es.
Bac
kgro
und
Pa
st li
tera
ture
sugg
ests
RC
I inc
orpo
rate
s rel
iabi
lity
in
calc
ulat
ion
of sm
all b
ut m
eani
ngfu
l cha
nge
in h
ealth
st
atus
ove
r tim
e1,2,
3.5
R
CI o
ffers
mor
e in
sigh
tful c
linic
al in
terp
reta
tions
than
gr
oup-
leve
l sta
tistic
s3,5
R
BA
NS
has l
evel
of d
iffic
ulty
app
ropr
iate
for n
orm
al
olde
r adu
lts th
roug
h in
divi
dual
s with
mod
erat
ely
seve
re
dem
entia
1,4
D
evel
opm
ent o
f “no
rmal
” re
gres
sion
-bas
ed c
hang
e al
gorit
hms a
llow
for b
road
er a
pplic
atio
n2,5
In
itial
per
form
ance
on
test
foun
d to
be
best
pre
dict
or o
f re
test
per
form
ance
2
A
ncho
r-bas
ed m
etho
ds c
onsi
dere
d pr
efer
red
appr
oach
6
Rel
iabl
e C
hang
e (R
CI)
on R
epea
tabl
e B
atte
ry fo
r the
Ass
essm
ent
of N
euro
psyc
holo
gica
l Sta
tus
(RB
AN
S) in
a D
emen
tia S
ampl
e
RE
SU
LTS
Ben
jam
in G
ould
1 , Jo
e En
right
1 , M
. E. O
’Con
nell1
, & D
ebra
Mor
gan2
1 D
epar
tmen
t of P
sych
olog
y, U
nive
rsity
of S
aska
tche
wan
, 2C
anad
ian
Cen
tre
for H
ealth
and
Saf
ety
in A
gric
ultu
re, U
nive
rsity
of S
aska
tche
wan
53
parti
cipa
nts (
57%
fem
ale)
at t
he R
ural
and
Rem
ote
Mem
ory
Clin
ic w
ho w
ere
diag
nose
d w
ith d
emen
tia b
ased
on
inte
rvie
w w
ith p
atie
nt a
nd fa
mili
es in
add
ition
to:
R
ecen
t blo
od w
ork
C
T he
ad sc
an
Neu
rolo
gica
l ass
essm
ent
N
euro
psyc
holo
gica
l ass
essm
ent
Ph
ysic
al th
erap
y as
sess
men
tT
he sa
mpl
e on
ly in
clud
ed p
atie
nts w
ho c
ompl
eted
all
neur
opsy
chol
ogic
al v
aria
bles
at c
linic
day
and
1 y
ear
late
r
DIS
CU
SS
ION
Pers
ons f
rom
this
sam
ple
dem
onst
rate
d an
ove
rall
decl
ine
beyo
nd e
xpec
ted
base
d on
a c
ogni
tivel
y he
alth
y ol
der a
dult
sam
ple
on a
ll R
BA
NS
indi
ces (
Mea
n), b
ut in
divi
dual
va
riabi
lity
rega
rdin
g de
clin
e vs
stab
ility
vs i
mpr
ovem
ent w
as
seen
mos
t ofte
n on
the
Lang
uage
Inde
x. N
o pe
rson
with
de
men
tia im
prov
ed o
n Im
med
iate
Mem
ory.
Gen
eral
con
sist
ency
was
iden
tifie
d be
twee
n D
uff2
and
Phill
ip’s
6 m
eani
ngfu
l cha
nge
appr
oach
, but
imm
edia
te m
emor
y an
d to
tal s
cale
scor
e di
spla
yed
disc
repa
ncie
s.
RB
AN
S In
dex
–C
DR
cor
rela
tiona
l dat
a ch
alle
nges
the
utili
ty
of th
e C
DR
as a
n ap
prop
riate
anc
hor.
Futu
re D
irec
tions
Fu
ture
rese
arch
will
aim
toex
plor
eth
e di
sagr
eem
ent
pres
ent b
etw
een
the
RC
I and
MC
ID a
ppro
ache
s, an
d th
e di
scre
panc
ies i
n pa
rtici
pant
per
form
ance
(i.e
, im
prov
ed
scor
es).
1 Atti
x, D
. K.,
Stor
y, T.
J.,
Che
lune
, G. J
., Ba
ll, J
. D.,
Stut
ts, M
. L.,
Har
t R. P
., &
Barth
J. T
. (20
09).
The
pred
ictio
n of
Cha
nge:
Nor
mat
ive
neur
opsy
chol
ogic
al tr
ajec
torie
s, T
he C
linic
al N
euro
psyc
holo
gist
, 23(
1), 2
1-38
.2 D
uff,
K., S
choe
nber
g, M
. R.,
Patto
n, D
., Pa
ulse
n, J
. S.,
Bayl
ess,
J. D
., M
old,
J.,
Scot
t, J.
G.,
& Ad
ams,
R. L
. (20
05).
Reg
ress
ion-
base
d fo
rmul
as
for p
redi
ctin
g ch
ange
in R
BAN
S su
btes
ts w
ith o
lder
adu
lts, A
rchi
ves
of C
linic
al N
euro
psyc
holo
gy, 2
0, 2
81-2
90.
3 Sch
mitt
, J. S
., &
Di F
abio
, P. D
. (20
04).
Rel
iabl
e ch
ange
and
min
imum
impo
rtant
diff
eren
ce (M
ID) p
ropo
rtion
s fa
cilit
ated
gro
up re
spon
sive
ness
co
mpa
rison
s us
ing
indi
vidu
al th
resh
old
crite
ria, J
ourn
al o
f Clin
ical
Epi
dem
iolo
gy, 5
7, 1
008-
1018
.4 H
obso
n, V
. L.,
Hal
l, J.
R.,
Hum
phre
ys-C
lark
, J. D
., Sc
hrim
sher
, G. W
., &
O’B
ryan
t, S.
E. (
2010
). Id
entif
ying
func
tiona
l im
pairm
ent w
ith s
core
s fro
m th
e re
peat
able
bat
tery
for t
he a
sses
smen
t of n
euro
psyc
holo
gica
l sta
tus
(RBA
NS)
, Int
erna
tiona
l Jou
rnal
of G
eria
tric
Psy
chia
try, 2
5, 5
25-5
30.
5 Duf
f, K.
, Sch
oenb
erg,
M. R
., Pa
tton,
D.,
Mol
d, J
., Sc
ott,
J. G
., &
Adam
s, R
. L. (
2004
). Pr
edic
ting
chan
ge w
ith th
e R
BAN
S in
a c
omm
unity
dw
ellin
g el
derly
sam
ple,
Jou
rnal
of t
he In
tern
atio
nal N
euro
psyc
holo
gica
l Soc
iety
, 10,
828
-834
.
Min
M
axM
SD
Patie
nt a
ge a
t clin
ic d
ay44
9270
.79
10.9
1
Form
al E
duca
tion
416
11.4
52.
67
Dia
gnos
isf
Alz
heim
er’s
dis
ease
28Va
scul
ar d
emen
tia4
Fron
tote
mpo
ral d
emen
tia (F
TD)
FTD
,fro
ntal
var
iant
7FT
D,s
eman
tic v
aria
nt1
FTD
,pro
gres
sive
non
-flu
ent
1D
emen
tia m
ultip
leae
tiolo
gies
6D
emen
tiam
edic
al c
ondi
tion
3D
emen
tia w
ithLe
wy
bodi
es3
Tota
l53
RB
AN
SIn
dex
RC
I&
MC
IDE
xcee
ded
(%)
RC
IE
xcee
ded
&M
CID
M
isse
d(%
)
RC
IM
isse
d &
M
CID
Exc
eede
d(%
)
RC
I &
MC
IDM
isse
d(%
)
%A
gree
d
Imm
edia
te
Mem
ory
16(3
0.2)
31 (5
8.4)
3 (5
.7)
3 (5
.7)
36%
Vis
uosp
atia
l32
(60.
3)11
(20.
8)10
(18.
9)0
(0)
60%
Lang
uage
14
(26.
4)0
(0)
7 (1
3.2)
32 (6
0.3)
87%
Atte
ntio
n20
(37.
7)0
(0)
17 (3
2.1)
16 (3
0.2)
68%
Del
ayed
M
emor
y14
(26.
4)10
(18.
9)10
(18.
9)19
(35.
8)62
%
Tota
l Sca
le15
(28.
3)31
(58.
5)4
(7.5
)3
(5.7
)34
%
Pr
edet
erm
ined
regr
essi
on fo
rmul
as to
det
erm
ine
pred
icte
d re
-test
scor
esfo
r per
sons
with
dem
entia
Pr
edic
ted
re-te
stin
dex
com
pare
d to
act
ual s
core
s2
R
egre
ssio
n-ba
sed
chan
ge sc
ores
com
pare
d to
anc
hor-
base
d cu
t-offs
6
C
orre
latio
n be
twee
n R
BA
NS
Inde
x sc
ores
and
Clin
ical
D
emen
tia R
atin
g fo
r util
ity a
s an
anch
or-b
ased
mea
sure
ME
TH
OD
RR
MC
Fun
ding
and
in-k
ind
supp
ort i
s ge
nero
usly
pro
vide
d by
:
RB
AN
SIn
dex
Cor
rela
tion
with
CD
Rr(
p)R
BA
NS-
Imm
edia
te M
emor
y.1
29 (p
> 0.
05)
RB
AN
S-V
isuo
spat
ial/C
onst
ruct
.013
(p>
0.05
)R
BA
NS-
Lang
uage
Inde
x.0
56 (p
> 0.
05)
RB
AN
S-A
ttent
ion
Inde
x.2
06 (p
> 0.
05)
RB
AN
S-D
elay
ed M
emor
y.0
94 (p
> 0.
05)
RB
AN
S-To
tal S
cale
.147
(p>
0.05
)
RE
SU
LTS
Con
tact
RB
AN
SIn
dex
Ran
ge o
f D
iffer
ence
Sc
ores
Pred
icte
d-A
ctua
l Mea
nSc
ores
# o
f Re-
scor
es
high
er th
an
Pred
icte
dIm
mM
emor
y2.
01 –
79.5
7 35
.11
0V
isuo
spat
ial
-1.7
7 –
75.7
433
.39
1La
ngua
ge
-18.
98 –
37.6
58.
7812
Atte
ntio
n -2
3.72
–50
.76
12.3
57
Del
Mem
ory
-17.
64 –
47.2
115
.87
6
11
•Th
is re
sear
ch is
in c
olla
bora
tion
with
the
com
mun
ities
’ men
tal w
elln
ess
initi
ativ
e:
“Com
plet
ing
the
Circ
le o
f Men
tal W
elln
ess
Car
e in
P
rince
Edw
ard
Isla
nd F
irst N
atio
n C
omm
uniti
es,
Pha
se 1
: Gat
herin
g S
treng
th a
nd K
now
ledg
e”.
•Th
eore
tical
Fra
mew
ork:
•Al
l wor
k in
this
pro
ject
has
and
will
be a
ppro
ache
d th
roug
h an
Indi
geno
us p
arad
igm
that
pla
ces
emph
asis
on
rela
tiona
l net
wor
ks4 .
•St
udy
1: U
nder
stan
ding
Com
mun
al N
eeds
•W
e ai
m to
exp
lore
the
com
mun
ity p
erce
ived
men
tal
wel
lnes
s ne
eds
thro
ugh
Pho
tovo
ice.
•P
hoto
voic
eal
low
s th
e co
mm
unity
to c
omm
unic
ate
thei
r sto
ries
and
desc
ribe
thei
r tho
ught
s th
roug
h a
cultu
rally
app
ropr
iate
mod
ality
5 .
•St
udy
2: S
elf-r
efle
ctiv
e Et
hnog
raph
y on
Rel
atio
ns•
An e
thno
grap
hic
writ
ing
appr
oach
allo
ws
us to
be
sens
itive
to th
e in
fluen
ces
of in
dige
nous
vi
ewpo
ints
, bel
iefs
and
pra
ctic
es, b
ehav
iour
s an
d pr
oces
ses6
.
INT
RO
DU
CT
ION
Purp
ose
•To
exp
lore
the
men
tal w
elln
ess
need
s of
two
Can
adia
n Ab
orig
inal
com
mun
ities
resi
ding
in P
rince
Ed
war
d Is
land
(PEI
) -S
tudy
1.
•To
furth
er u
nder
stan
d th
e im
porta
nce
and
impl
icat
ions
of r
esea
rche
r-com
mun
ity re
latio
ns fr
om
an in
side
r-out
side
r per
spec
tive
-Stu
dy 2
.
•Su
rvey
ing
the
cultu
ral r
espo
nsiv
enes
s of
the
inno
vativ
e te
chno
logi
es d
esig
ned
by A
GE-
WEL
L to
im
prov
e qu
ality
of l
ife in
old
er a
dults
-S
tudy
3.
Rat
iona
le•
Res
earc
h in
Indi
geno
us m
enta
l hea
lth re
mai
ns
high
ly u
nder
stud
ied,
lead
ing
to c
once
rns
in
unde
rsta
ndin
g ap
prop
riate
ser
vice
s to
Indi
geno
us
com
mun
ities
1 .
•R
esea
rch
has
sugg
este
d th
at ra
cial
-eth
nic
heal
th
disp
ariti
es (e
.g.,
Indi
geno
us h
ealth
) are
par
tly
pres
ent d
ue to
a la
ck o
f tru
st b
etw
een
patie
nt a
nd
heal
thca
re p
rovi
der,
supp
ortin
g th
e im
porta
nce
of
build
ing
trust
and
stre
ngth
enin
g re
latio
nshi
ps2 .
•Th
e de
velo
pmen
t of c
ultu
rally
saf
e, u
sefu
l te
chno
logy
can
onl
y be
dev
elop
ed b
y a
coop
erat
ive
parti
cipa
tion
with
Indi
geno
us e
nd-u
sers
and
co
mm
unity
3 .
Expl
orin
g M
i’km
aq C
omm
uniti
es’ M
enta
l Wel
lnes
s N
eeds
: U
nder
stan
ding
the
App
ropr
iate
App
roac
hes
to Im
prov
ing
Qua
lity
of L
ifeG
ould
, B.1 ,
O’C
onne
ll, M
. E.1 ,
Bou
rass
a, C
.2,3 ,
Jack
lin, K
.4 , C
arte
r, J.
1 1 U
nive
rsity
of S
aska
tche
wan
, 2 U
nive
rsity
if R
egin
a, 3 F
irst N
atio
ns U
nive
rsity
of C
anad
a, 4 N
orth
ern
Ont
ario
Sch
ool o
f Med
icin
e
•Th
e fo
cus
of th
is p
roje
ct w
orks
with
Abe
gwei
tand
Le
nnox
Isla
nd F
irst N
atio
ns’ c
omm
uniti
es fr
om P
EI:
•Le
nnox
Isla
nd R
eser
vatio
n •
Scot
chfo
rtR
eser
vatio
n•
Roc
ky P
oint
Res
erva
tion
•M
orel
l Res
erva
tion
•O
ther
par
tner
s in
clud
e:
•M
i’km
aq C
onfe
dera
cy o
f PE
I •
Men
tal H
ealth
& A
ddic
tions
, PE
I Dep
t. of
Hea
lth•
Dep
t. of
Hea
lth &
Wel
lnes
s, P
EI D
ept.
of H
ealth
•U
nive
rsity
of P
EI
•Fi
rst N
atio
n In
uit H
ealth
Bra
nch
Ref
eren
ces
1 Ki
rmay
er, L
. J.,
Gill,
K.,
Flet
cher
, C.,
Tern
ar, Y
., Bo
othr
oyd,
L.,
& Q
uesn
ey, C
. (19
94).
Emer
ging
tren
ds in
rese
arch
on
men
tal h
ealth
am
ong
Can
adia
n Ab
orig
inal
peo
ples
. A re
port
prep
ared
for t
he R
oyal
Com
mis
sion
on
Abo
rigin
al P
eopl
es.
Otta
wa,
ON
: Gov
ernm
ent o
f Can
ada.
2 Si
mon
ds, V
.W.,
Goi
ns, R
.T.,
Kran
tz, E
.M. &
Gar
rout
te, E
.M. (
2013
). C
ultu
ral I
dent
ity a
nd p
atie
nt tr
ust a
mon
g ol
der
Amer
ican
Indi
ans.
Jou
rnal
of G
ener
al In
tern
al M
edic
ine,
29(
3), 5
00-5
06. D
OI:
10.1
007/
s116
06-0
13-2
578-
y3 M
aar,
M. A
., Se
ymou
r, A.
, San
ders
on, B
., &
Boes
ch, L
. (20
10).
Rea
chin
g ag
reem
ent f
or a
n Ab
orig
inal
e-h
ealth
rese
arch
ag
enda
: The
Abo
rigin
al T
eleh
ealth
kno
wle
dge
circ
le c
onse
nsus
met
hod.
Rur
al a
nd R
emot
e H
ealth
, 10,
129
9-13
12.
4 W
ilson
, S. (
2008
). R
esea
rch
is c
erem
ony:
Indi
geno
us re
sear
ch m
etho
ds.
5 Cas
tlede
n, H
., &
Gar
vin,
T. (
2008
). M
odify
ing
Phot
ovoi
cefo
r com
mun
ity-b
ased
par
ticip
ator
y In
dige
nous
rese
arch
. Soc
ial s
cien
ce &
m
edic
ine,
66(
6), 1
393-
1405
.6 L
oppi
ng, C
. (20
07).
Lear
ning
from
gra
ndm
othe
rs: I
ncor
pora
ting
Indi
geno
us p
rinci
ples
into
qua
litat
ive
rese
arch
. Qua
litat
ive
Hea
lth
Res
earc
h, 1
7(2)
, 276
-284
. 7 L
aval
lée,
L. F
. (20
09).
Prac
tical
app
licat
ion
of a
n In
dige
nous
rese
arch
fram
ewor
k an
d tw
o qu
alita
tive
Indi
geno
us re
sear
ch m
etho
ds:
Shar
ing
circ
les
and
Anis
hnaa
besy
mbo
l-bas
ed re
flect
ion.
Inte
rnat
iona
l jou
rnal
of q
ualit
ativ
e m
etho
ds, 8
(1),
21-4
0.
Met
ho
d
RR
MC
Fun
ding
and
in-k
ind
supp
ort i
s ge
nero
usly
pro
vide
d by
:
•St
udy
3: T
echn
olog
y &
Cul
tura
l Res
pons
iven
ess
•S
harin
g C
ircle
s w
ill be
util
ized
, brin
ging
the
com
mun
ities
toge
ther
to s
hare
and
exp
lore
thei
r im
pres
sion
s to
war
ds A
GE-
WEL
L te
chno
logi
es.
•Th
ough
sim
ilar t
o fo
cus
grou
ps, S
harin
g C
ircle
s pr
ovid
e sa
cred
mea
ning
in m
any
Indi
geno
us
cultu
res
and
prom
ote
grow
th a
nd tr
ansf
orm
atio
n fo
r th
ose
invo
lved
7 .
Par
tner
sM
eth
od
12
Kae
li K
nuds
en1 ,
Ryan
Hei
stad
1 , Je
nnife
r N.K
. Nya
rko1
, Jus
tine
Gre
er1 ,
Car
los E
. Car
valh
o2 ,
and
Dar
rell
D. M
ouss
eau1
1 Dep
artm
ento
f Psy
chia
try, U
nive
rsity
of S
aska
tche
wan
, Sas
kato
on, S
7N 5
E2, C
anad
a. 2 D
epar
tmen
t of B
iolo
gy, U
nive
rsity
of S
aska
tche
wan
, Sas
kato
on, S
7N 5
E2, C
anad
a
Expo
sed
to
Fluo
xetin
e or
Nor
fluox
etin
e
Dev
elop
men
t cha
rt of
the
C. e
lega
nsX
X g
erm
line
Intro
duct
ion
Ther
ear
ea
num
bero
fstu
dies
that
have
show
na
link
betw
een
depr
essi
onan
dA
lzhe
imer
’sdi
seas
e(A
D),
whe
repe
ople
suffe
ring
from
depr
essi
onha
vea
muc
hgr
eate
rch
ance
atde
velo
ping
AD
com
pare
dto
men
tally
heal
thy
indi
vidu
als
(Ow
nby
etal
.,20
06;M
eltz
eret
al,1
998;
and
Tara
gano
etal
,19
97).
Seve
rals
tudi
esha
vesh
own
that
the
risk
ofde
velo
ping
AD
/dem
entia
varie
dbe
twee
nde
pres
sed
patie
nts
and
actu
ally
alig
ned
mor
ew
ithth
ety
peof
antid
epre
ssan
tdru
gus
edto
treat
the
depr
essio
n(K
essi
nget
al,
2009
).Th
ehi
ghes
tris
kw
asas
soci
ated
with
the
clas
sof
antid
epre
ssan
tdr
ugs
calle
dse
lect
ive
sero
toni
nre
upta
kein
hibi
tors
(SSR
Is),
whi
chbl
ock
the
chan
nels
that
rem
ove
sero
toni
nfro
mth
esy
naps
e.Th
ere
isa
poss
ibili
tyth
atby
inhi
bitin
gth
ese
chan
nels
,β-a
myl
oid
(Aβ)
,apr
otei
nth
atis
thou
ghtt
oco
ntrib
ute
toth
epa
thol
ogy
asso
ciat
edto
AD
may
bepr
even
ted
from
leav
ing
the
cell.
Agg
rega
tion
may
beoc
curri
ngby
som
eof
the
prot
ein
atta
chin
gto
the
clos
edch
anne
l,al
low
ing
accu
mul
atio
nto
occu
rmor
eea
sily
.
•D
iffer
ent e
ffect
s ar
e al
so se
en b
etw
een
the
CL2
120
and
GM
C10
1 w
orm
s.•
Ther
e ar
e di
ffere
nces
bet
wee
n th
e tre
atm
ents
, but
incr
ease
d sa
mpl
e si
zes
will
be
requ
ired
to d
eter
min
e st
atis
tical
sig
nific
ance
.•
We
will
test
a C
. ele
gans
stra
in th
at la
cks t
he m
od-5
trans
porte
r (th
e w
orm
an
alog
ue o
f the
sero
toni
n tra
nspo
rter)
. The
se w
orm
s will
be
cros
sed
with
th
e G
MC
101
wor
ms.
The
lack
of m
od-5
will
be
the
mol
ecul
ar c
ount
erpa
rt to
pha
rmac
olog
ical
inhi
bitio
n of
sero
toni
n tra
nspo
rt, a
nd w
ill re
mov
e an
y co
ncer
n ab
out o
ff-ta
rget
effe
cts
of th
e an
tidep
ress
ant d
rugs
bei
ng te
sted
.
Con
clus
ions
Tote
stfo
rth
eef
fect
sof
SSR
Ison
the
accu
mul
atio
nof
Aβ,
we
used
the
C.e
lega
nsw
orm
.The
sew
orm
sar
ero
utin
ely
used
tostu
dya
varie
tyof
path
olog
ies
asso
ciat
edw
ithag
ing
and/
orne
urod
egen
erat
ion.
The
C.e
lega
nsw
orm
does
not
prod
uce
Aβ,
soit
isa
good
orga
nism
tote
stho
wth
eex
pres
sion
ofhu
man
Ab
can
affe
ctvi
abili
ty,a
ging
,cel
ldea
thet
c.W
ech
ose
tous
etw
odi
ffere
ntst
rain
s;G
MC
101
prod
uces
the
Aβ 1
-42
prot
ein
(mos
tof
ten
asso
ciat
edw
ithA
D)a
ndC
L212
0pr
oduc
esan
N-tr
unca
ted
varia
nt(A
β 3-4
2)pr
otei
n,w
hose
role
into
xici
tyis
nots
ocl
ear.
Phen
otyp
ical
ly,o
nce
the
wor
msh
ave
Aβ
aggr
egat
ion
they
appe
arpa
raly
zed
and
unre
spon
sive
.We
teste
dw
heth
ertw
oSS
RIs
,i.e
.flu
oxet
ine
orits
met
abol
iteno
rfluo
xetin
e,co
uld
alte
rthe
rate
ofpa
raly
sisi
nth
ese
two
wor
mst
rain
s.
Met
hod
Kes
sing
L, S
onde
rgar
dL,
For
man
J, a
nd A
nder
son
P. (
2009
). A
ntid
epre
ssan
ts a
nd d
emen
tia. J
ourn
al o
f Affe
ctiv
e D
isor
ders
. 117
, 24-
29.
Mel
tzer
C, S
mith
G, f
luox
etin
e vs.
amitr
ipty
line i
n th
e tre
atm
ent o
f maj
or d
epre
ssio
n co
mpl
icat
ing
Alz
heim
er’s
dis
ease
. Ps
ycho
som
atic
s, 38
, 246
-252
DeK
osky
S, P
ollo
ck B
, Mat
his C
, Moo
re R
, Kup
ferD
, and
Rey
nold
s C. (
1998
). Se
roto
nin
in
agin
g, la
te-li
fe d
epre
ssio
n, a
nd A
lzhe
imer
’s d
isea
se: t
he e
mer
ging
role
of f
unct
iona
l im
agin
g. N
euro
psyc
hoph
arm
acol
ogy,
18
(6).
Ow
nby
R, C
rocc
oE,
Ace
vedo
A, J
ohn
V, a
nd L
oew
enst
ein
D. (
2006
). D
epre
ssio
n an
d ris
k fo
r Alz
heim
er’s
dis
ease
sy
stem
ic re
view
, met
a-an
alys
is a
nd m
etar
eges
sion
anal
ysis
. Arc
h G
en P
sych
iatr
y, 63
(5),
530-
538.
Tara
gano
F, L
yket
osos
C, M
ango
neC
, Alle
gri R
, and
Com
esan
a-D
iaz,
E. (
1997
). A
dou
ble-
blin
d, ra
ndom
ized
, fix
ed-d
ose
trial
of f
luox
etin
e vs
. am
itrip
tylin
e in
the
treat
men
t of m
ajor
dep
ress
ion
com
plic
atin
g A
lzhe
imer
’s d
isea
se.
Psyc
hoso
mat
ics,
38, 2
46-2
52
Ref
eren
ces
Res
ults Tr
eate
d w
ith F
luox
etin
e us
ing
Live
E. c
oli
Trea
ted
with
Nor
fluox
etin
eus
ing
Live
E. c
oli
Trea
ted
with
Flu
oxet
ine
usin
g D
ead
E. c
oli
Trea
ted
with
Nor
fluox
etin
eus
ing
Dea
d E.
col
i
Ack
now
ledg
men
tsD
DM
is th
e Sa
skat
chew
an R
esea
rch
Cha
ir in
Alz
heim
er d
iseas
e and
rela
ted
dem
entia
fund
ed jo
intly
by
the A
lzhe
imer
Soc
iety
of S
aska
tche
wan
and
the
Sask
atch
ewan
Hea
lth R
esea
rch
Foun
datio
n
13
Back
grou
ndR
esul
tsAt
tent
ion
in p
revi
ous
stud
ies
of h
ealth
ser
vice
use
dur
ing
the
perio
ds
befo
re a
nd a
fter d
emen
tia id
entif
icat
ion
has
focu
sed
on th
e vo
lum
e or
fre
quen
cy o
f ser
vice
use
1-3 ,
parti
cula
rly th
e pe
riods
of h
eavi
est u
se2 ,
and
whe
ther
dem
entia
con
tribu
tes
to in
crea
sed
use
whe
n ho
ldin
g ot
her
fact
ors
cons
tant
3 . H
owev
er, t
he b
rief p
erio
ds ty
pica
lly e
xam
ined
in
thes
e st
udie
s (1
-3 y
ears
) do
not a
dequ
atel
y ac
coun
t for
the
long
tra
ject
ory
of th
e he
lp-s
eeki
ng c
aree
r of s
ome
indi
vidu
als
with
dem
entia
an
d th
eir f
amilie
s.Th
is s
tudy
exa
min
ed p
atte
rns
in h
ealth
ser
vice
use
am
ong
indi
vidu
als
with
inci
dent
dem
entia
com
pare
d to
a m
atch
ed g
ener
al
olde
r adu
lt (G
OA)
coh
ort i
n th
e 5-
year
pre
-inde
x pe
riod
lead
ing
up to
id
entif
icat
ion
and
the
5-ye
ar p
ost-i
ndex
per
iod
afte
r ide
ntifi
catio
n.
Dis
clai
mer
:Th
is s
tudy
is b
ased
in p
art o
n de
-iden
tifie
d da
ta p
rovi
ded
by th
e Sa
skat
chew
an M
inis
try o
f H
ealth
.Th
e in
terp
reta
tions
and
con
clus
ions
her
ein
do n
ot n
eces
saril
y re
pres
ent t
hose
of t
he
Gov
ernm
ent o
f Sas
katc
hew
an o
r the
Min
istry
of H
ealth
.
Varia
ble Nam
eDem
entia
(N=3,227)
GOA
(N=3,227)
p‐values fo
r mean
compa
rison
tests
Mean
S.D.
Mean
S.D.
Prop
ensity Scores
0.13
0.17
0.13
0.17
0.68
Age grou
p44
‐54
2.6%
0.16
2.6%
0.16
0.94
55‐64
4.9%
0.22
4.8%
0.21
0.91
65‐74
10.7%
0.31
11.6%
0.32
0.29
75+
81.7%
0.39
81.0%
0.39
0.44
Male, % of p
atients
40.2%
0.49
39.2%
0.49
0.43
Urban
*64
.1%
0.48
64.5%
0.48
0.80
Charlson
Inde
x1.81
2.13
1.81
2.09
0.99
Charlson
Flag δ
<0.2%
s<0.2%
s1.00
Region
al Health
Autho
rity
Sun Co
untry
6.6%
0.25
6.9%
0.25
0.69
Five Hills
6.2%
0.24
6.3%
0.24
0.84
Cypress
6.0%
0.24
6.1%
0.24
0.83
Regina
Qu’Ap
pelle
22.3%
0.42
22.4%
0.42
0.98
Sunrise
9.0%
0.29
9.0%
0.29
0.93
Saskatoo
n24
.8%
0.43
25.0%
0.43
0.84
Heartland
5.9%
0.24
5.7%
0.23
0.71
Kelsey Trail
5.6%
0.23
5.5%
0.23
0.91
Prince Albert P
arklan
d7.3%
0.26
7.2%
0.26
0.85
Prairie
North
5.4%
0.23
5.0%
0.22
0.50
Mam
awetan
Churchill River
0.4%
0.06
0.5%
0.07
0.56
Keew
atin Yatthé
δ<0.2%
s<0.2%
s1.00
Atha
basca
δ<0.2%
s<0.2%
s1.00
*A re
sident w
as categorize
d as living
in an urban area
if his/he
r postal cod
e was in
a Cen
sus Metropo
litan
Area
or Cen
sus Ag
glom
eration with
a pop
ulation of 10,000 or m
ore.
δValues are sup
pressed du
e to privacy.
Fam
ily P
hysi
cian
(FP)
•Th
e pr
opor
tion
of th
e de
men
tia c
ohor
t with
>1
FP v
isit
was
rela
tivel
y st
able
acr
oss
the
stud
y pe
riod,
pea
king
at 1
-yr p
re-in
dex.
•
A si
gnifi
cant
ly g
reat
er p
ropo
rtion
of t
he d
emen
tia th
an G
OA
coho
rt ha
d >1
FP
visi
t at 1
-yr p
ost-i
ndex
(p<
0.05
).
•Am
ong
the
dem
entia
coh
ort,
the
unad
just
ed m
ean
num
ber o
f vis
its in
crea
sed
stea
dily
ove
r the
pre
-inde
x pe
riod
befo
re s
piki
ng a
t 1-
yr p
ost-i
ndex
, rem
aini
ng a
t a h
ighe
r lev
el (r
elat
ive
to p
re-in
dex)
for t
he d
urat
ion
of th
e po
st-in
dex
perio
d.•
The
unad
just
ed m
ean
num
ber o
f vis
its w
as s
igni
fican
tly h
ighe
r am
ong
the
dem
entia
than
GO
A co
hort
over
the
entir
e st
udy
perio
d (p
< 0.
05).
Coh
ortc
reat
ion
•D
ata
wer
e ex
tract
ed fr
om 7
pro
vinc
ial a
dmin
istra
tive
heal
th
data
base
s lin
ked
by a
uni
que
anon
ymiz
ed ID
num
ber.
•Th
e de
men
tia c
ohor
tinc
lude
d in
divi
dual
s 45
yea
rs a
nd o
lder
at t
heir
first
-eve
r rec
orde
d id
entif
icat
ion
of d
emen
tia (i
ndex
dat
e) b
etw
een
April
1, 2
008
and
Mar
ch 3
1, 2
009.
Inci
dent
cas
es s
atis
fied
case
de
finiti
on c
riter
ia th
at in
clud
ed >
1 ph
ysic
ian
visi
t OR
>1
hosp
italiz
atio
n O
R >
1 pr
escr
iptio
n fo
r a c
holin
este
rase
inhi
bito
r OR
Lo
ng-te
rm C
are
(RAI
-MD
S) C
ogni
tive
Perfo
rman
ce S
cale
sco
re o
f 2
or o
ver a
nd/o
r a d
isea
se c
ateg
ory
of A
D o
r oth
er d
emen
tia (s
ee
Kost
eniu
k et
al.4
for t
he c
riter
ia a
nd fu
rther
det
ails
in th
e or
igin
al
stud
y).
•Ea
ch in
divi
dual
in th
e de
men
tia c
ohor
t was
mat
ched
one
-to-o
ne w
ith
a ge
nera
l old
er a
dult
(GO
A) b
y pr
open
sity
sco
re m
atch
ing
on s
ix
varia
bles
at o
r 1-y
r prio
r to
inde
x da
te. T
he c
hara
cter
istic
s of
the
final
m
atch
ed c
ohor
ts s
tratif
ied
by th
e si
x m
atch
ing
varia
bles
are
det
aile
d in
Tab
le 1
.
Dat
a an
alys
is•
Des
crip
tive
stat
istic
s w
ere
used
to e
xam
ine
year
ly u
nadj
uste
dhe
alth
se
rvic
e us
e am
ong
the
dem
entia
and
mat
ched
GO
A co
horts
ove
r a 5
-ye
ar p
re-in
dex
and
5-ye
ar p
ost-i
ndex
per
iod
rela
tive
to fi
rst d
emen
tia
iden
tific
atio
n (in
dex
perio
d Ap
ril 1
, 200
8 to
Mar
ch 3
1, 2
009)
.
•Si
nce
the
dem
entia
and
GO
A co
horts
wer
e m
atch
ed o
n at
tribu
tes
at
inde
x da
te, n
egat
ive
bino
mia
l and
line
ar re
gres
sion
wer
e us
ed to
co
mpa
re p
ost-i
ndex
coh
ort d
iffer
ence
s be
twee
n th
e de
men
tia a
nd
GO
A co
hort
whi
le c
ontro
lling
for a
num
ber o
f fac
tors
. Spe
cific
ally,
m
odel
s w
ere
adju
sted
for a
ge a
t ind
ex d
ate,
sex
, 1-y
r prio
r Cha
rlson
Co-
mor
bidi
ty In
dex,
hea
lth re
gion
, rur
al/u
rban
resi
denc
e, a
nd 1
-yr
prio
r hea
lth s
ervi
ce u
se.
CC
NA
Team
20
Rur
al: A
retro
spec
tive
mat
ched
cas
e co
ntro
l coh
ort s
tudy
of h
ealth
ser
vice
use
ove
r a 1
0-ye
ar p
erio
d by
in
divi
dual
s w
ith in
cide
nt d
emen
tia in
Sas
katc
hew
an, C
anad
a Ju
lie K
oste
niuk
1 , D
ebra
Mor
gan1
, Bel
izAc
anO
sman
2 , Ja
cque
line
Qua
il2, M
egan
O’C
onne
ll1, A
ndre
w K
irk1 ,
Nor
ma
Stew
art1 ,
Mer
icO
sman
21 U
nive
rsity
of S
aska
tche
wan
, 2Sa
skat
chew
an H
ealth
Qua
lity
Cou
ncil
We
obse
rved
dis
tinct
pat
tern
s in
the
prop
ortio
n of
the
dem
entia
co
hort
usi
ng h
ealth
ser
vice
s:•
The
prop
ortio
n w
ith >
1 fa
mily
phy
sici
an v
isits
or >
1 dr
ug
disp
ensa
tions
was
rela
tivel
y st
able
acr
oss
the
stud
y pe
riod
•Th
e pr
opor
tion
with
>1
spec
ialis
t vis
it w
as h
ighe
r dur
ing
the
pre-
inde
x th
an p
ost-i
ndex
per
iod
•H
ospi
taliz
atio
n (>
1 ad
mis
sion
) spi
ked
at 1
-yr p
re-in
dex
and
stab
ilized
at 2
-yr p
ost-i
ndex
•Lo
ng-te
rm c
are
adm
issi
on (>
1) w
as p
ropo
rtion
ally
hig
her i
n th
e po
st-in
dex
than
pre
-inde
x pe
riod
We
also
iden
tifie
d di
stin
ct p
atte
rns
in u
nadj
uste
d av
erag
e he
alth
se
rvic
e us
e am
ong
the
dem
entia
coh
ort:
•Th
e m
ean
num
ber o
f fam
ily p
hysi
cian
vis
its a
nd d
rug
disp
ensa
tions
incr
ease
d ov
er th
e pr
e-in
dex
perio
d, a
nd w
ere
high
er in
the
post
-inde
x th
an p
re-in
dex
perio
d •
The
mea
n nu
mbe
r of s
peci
alis
t vis
its in
crea
sed
over
the
pre-
inde
x pe
riod,
sta
biliz
ing
post
-inde
x to
a le
vel s
imila
r to
pre-
inde
x•
The
mea
n nu
mbe
r of h
ospi
tal a
nd lo
ng-te
rm c
are
adm
issi
ons
wer
e re
lativ
ely
stab
le o
ver t
he e
ntire
stu
dy p
erio
d
The
grea
test
diff
eren
ces
betw
een
the
dem
entia
and
GO
A co
hort
s in
adj
uste
d av
erag
e se
rvic
e us
e w
ere
obse
rved
1-y
r po
st-in
dex
(all
p<0.
01; d
ata
not s
how
n). C
ompa
red
to th
e G
OA
coho
rt, th
e de
men
tia c
ohor
t exp
erie
nced
:•
12.5
(95.
1%) m
ore
phys
icia
n vi
sits
(inc
lude
s al
l FPs
and
sp
ecia
lists
)•
0.33
(74.
1%) m
ore
hosp
ital a
dmis
sion
s•
11.9
(44%
) mor
e dr
ug d
ispe
nsat
ions
By e
xam
inin
g pa
ttern
s in
the
use
of d
iscr
ete
heal
th c
are
serv
ices
by
indi
vidu
als
with
dem
entia
in th
e tim
e le
adin
g up
to id
entif
icat
ion,
and
di
rect
ly a
fter,
and
how
thes
e pa
ttern
s de
viat
e fro
m th
e no
rm, s
ervi
ces
can
be b
ette
r cal
ibra
ted
to th
e un
ique
nee
ds o
f thi
s gr
oup.
Fig.
7
Fig.
8
•Th
e pr
opor
tion
of th
e de
men
tia c
ohor
t with
>1
hosp
ital a
dmis
sion
was
gr
eate
st a
t 1-y
r pre
-inde
x an
d 1-
yr p
ost-i
ndex
.
•A
sign
ifica
ntly
gre
ater
pro
porti
on o
f the
dem
entia
than
GO
A co
hort
was
ho
spita
lized
>1
time
at 1
-yr p
re-in
dex
and
1-yr
pos
t-ind
ex (p
< 0.
05).
•Th
e pr
opor
tion
of th
e de
men
tia c
ohor
t with
>1
drug
dis
pens
atio
n w
as
rela
tivel
y st
able
acr
oss
the
stud
y pe
riod,
pea
king
at
5-y
r pos
t-ind
ex.
•A
sign
ifica
ntly
low
er
prop
ortio
n of
the
dem
entia
th
an G
OA
coho
rt ha
d >1
dr
ug d
ispe
nsat
ion
durin
g th
e 1-
yr to
4-y
r pre
-inde
x pe
riod
(p<
0.05
).
•Th
e un
adju
sted
mea
n nu
mbe
r of
long
-term
car
e ad
mis
sion
s am
ong
the
dem
entia
coh
ort
was
rela
tivel
y st
able
ove
r the
en
tire
stud
y pe
riod.
•Th
e un
adju
sted
mea
n nu
mbe
r of
long
-term
car
e ad
mis
sion
s w
as s
igni
fican
tly h
ighe
r am
ong
the
dem
entia
than
GO
A co
hort
at 1
-yr a
nd 4
-yr p
re-in
dex,
as
wel
l as
1-yr
and
2-y
r pos
t-in
dex
(p<
0.05
).
Fig.
1
Fig.
2
The
adju
sted
coho
rt di
ffere
nce
in m
ean
num
ber o
f fam
ily p
hysi
cian
and
spe
cial
ist v
isits
(com
bine
d) w
as g
reat
est a
t 1-y
r pos
t-ind
ex,
with
12.
5 m
ore
visi
ts a
mon
g th
e de
men
tia th
an G
OA
coho
rt (p
< 0.
01; d
ata
not s
how
n).
Spec
ialis
t•
The
prop
ortio
n of
the
dem
entia
coh
ort w
ith >
1 sp
ecia
list v
isit
was
hig
her d
urin
g pr
e-in
dex
than
pos
t-ind
ex, p
eaki
ng a
t 1-y
r pre
-inde
x.•
Com
pare
d to
GO
A, th
e pr
opor
tion
of d
emen
tia c
ohor
t with
>1
visi
t was
sig
nific
antly
low
er a
cros
s th
e en
tire
10-y
r stu
dy p
erio
d (p
< 0.
05).
•Th
e un
adju
sted
mea
n nu
mbe
r of v
isits
am
ong
the
dem
entia
coh
ort i
ncre
ased
ove
r the
pre
-inde
x pe
riod,
and
sta
biliz
ed p
ost-i
ndex
toa
leve
l si
mila
r to
pre-
inde
x.•
The
unad
just
ed m
ean
num
ber o
f vis
its w
as s
igni
fican
tly lo
wer
am
ong
the
dem
entia
than
GO
A co
hort
at 2
-yr a
nd 3
-yr p
re-in
dex,
but
si
gnifi
cant
ly h
ighe
r at 1
-yr p
ost-i
ndex
(p<
0.05
).
Fig.
1
Fig.
3
•Th
e un
adju
sted
mea
n nu
mbe
r of h
ospi
tal a
dmis
sion
s am
ong
the
dem
entia
co
hort
was
rela
tivel
y st
able
ove
r the
stu
dy p
erio
d; th
ere
wer
e no
sig
nific
ant
coho
rt di
ffere
nces
at a
ny p
oint
.
•Th
e ad
just
edco
hort
diffe
renc
e in
mea
n nu
mbe
r hos
pita
lizat
ions
was
gre
ates
t at
1-yr
pos
t-ind
ex, w
ith 0
.33
mor
e vi
sits
am
ong
the
dem
entia
than
GO
A co
hort
(p<
0.01
; dat
a no
t sho
wn)
.
•Am
ong
the
dem
entia
coh
ort,
the
long
est a
vera
ge d
urat
ion
of h
ospi
tal s
tay
occu
rred
at 1
-yr p
re-in
dex.
•D
urat
ion
of h
ospi
tal s
tay
was
sig
nific
antly
hig
her a
mon
g th
e de
men
tia th
an
GO
A co
hort
from
the
poin
t of 2
-yr p
re-in
dex
forw
ard
(p<
0.05
).
Hos
pita
l
•Th
e un
adju
sted
mea
n nu
mbe
r of
dru
g di
spen
satio
ns a
mon
g th
e de
men
tia c
ohor
t inc
reas
ed
over
the
first
7 y
ears
of t
he 1
0-ye
ar s
tudy
per
iod.
•Th
e un
adju
sted
mea
n nu
mbe
r of
dru
g di
spen
satio
ns w
as
sign
ifica
ntly
hig
her a
mon
g th
e de
men
tia th
an G
OA
coho
rt ov
er
the
entir
e st
udy
perio
d (p
< 0.
001)
.
•Th
e ad
just
edco
hort
diffe
renc
e in
mea
n nu
mbe
r of d
rug
disp
ensa
tions
was
gre
ates
t at 1
-yr
pos
t-ind
ex, w
ith 1
1.9
mor
e di
spen
satio
ns a
mon
g th
e de
men
tia th
an G
OA
coho
rt (p
< 0.
01; d
ata
not s
how
n).
Dru
g D
ispe
nsat
ion
•Lo
ng-te
rm c
are
adm
issi
on
amon
g th
e de
men
tia c
ohor
t w
as p
ropo
rtion
ally
hig
her
durin
g th
e po
st-in
dex
than
pr
e-in
dex
perio
d, p
eaki
ng
at 1
-yr p
re-in
dex.
•Th
e pr
opor
tion
of th
e de
men
tia c
ohor
t with
>1
long
-term
car
e ad
mis
sion
w
as s
igni
fican
tly g
reat
er
amon
g th
e de
men
tia th
an
GO
A co
hort
each
yea
r fro
m
the
poin
t of 2
-yr p
re-in
dex
forw
ard
(p<
0.05
).
Long
-term
Car
e
Tabl
e 1
Met
hods
Con
clus
ions
Fig.
2Fi
g. 3
Fi
g. 1
Fig.
4Fi
g. 5
Fig.
6
Fig.
10
Fig.
9
References
1.Eakere
t al. Alzheimer’s disease and othe
r dem
entia
and
med
ical care utilizatio
n. Ann
als of Epidemiology
2001,
12:39‐45.
2.Ch
en et a
l. He
alth care resource utilisa
tionin prim
ary care prio
r to and after a
diagnosis of Alzh
eimer’s Disease. BMC
Geriatrics 2014, 1
4:76.
3.Schw
arzkop
f et a
l.He
alth care service utilizatio
n of dem
entia
patients before and
afte
r institutionalization: a claim
s data analysis
. Dem
entia
and
Geriatric Cog
nitive Disorders E
xtra 2014, 4:195
‐208.
4.Ko
sten
iuk et al. Incide
nce and prevalen
ce of d
ementia
in linked
adm
inistrativ
e he
alth data in Saskatche
wan,
Canada: a
retrospe
ctive coho
rt stud
y. BMC Geriatrics 2015, 1
5:73.
14
15
Tab
le 2
Wee
k 1
Wee
k 3
Wee
k 5
Wee
k 8
Did
the
tar
get
ed a
ctiv
ity
100%
100%
100%
100%
Trie
d t
o le
ave
the
acti
vity
0%0%
0%0%
Left
the
act
ivit
y o
n o
wn
or
wit
h st
aff
0%0%
0%4%
(n=
1)M
ore
tha
n ½
act
ivit
y co
mp
lete
82%
100%
90%
100%
List
ened
wat
ched
mo
re t
han
½ a
ctiv
ity
100%
100%
100%
100%
Att
end
ed t
o t
asks
oth
er t
han
the
acti
vity
4%4%
4%0%
Slep
t o
r st
ared
into
sp
ace
0%0%
0%0%
Exp
ress
ed p
leas
ure
mo
re t
han
½ a
ctiv
ity
33%
39%
32%
42%
Exp
ress
ed p
leas
ure
for
up t
o ½
act
ivit
y46
%50
%47
%38
%E
xpre
ssed
no
ple
asur
e33
%11
%21
%21
%D
isp
laye
d a
nxie
ty –
no
t at
all
100%
100%
100%
100%
Hel
ped
oth
ers
– no
t at
all
92%
88%
79%
71%
Hel
ped
oth
ers
– up
to
½ o
f ac
tivi
ty8%
8%16
%25
%H
elp
ed o
ther
s –
mo
re t
han
½ a
ctiv
ity
0%4%
5%4%
Act
ed in
app
rop
riat
ely
– no
t at
all
100%
100%
100%
100%
Min
ds
in M
oti
on®
is a
co
mm
unit
y-b
ased
fitn
ess
and
so
cial
act
ivit
y p
rog
ram
tha
t in
corp
ora
tes
phy
sica
l act
ivit
y an
d m
enta
l sti
mul
atio
n fo
r p
eop
le w
ith
earl
y sy
mp
tom
s o
f A
lzhe
imer
’s d
isea
se a
nd o
ther
dem
enti
as t
o e
njo
y w
ith
a fr
iend
or
fam
ily m
emb
er.
Pilo
t to
ok
pla
ce in
Sas
kato
on
fro
m J
uly
2015
– M
ay 2
016
Ho
w t
he p
rog
ram
wo
rks
A t
wo
ho
ur, w
eekl
y p
rog
ram
tha
t ru
ns f
or
eig
ht c
ons
ecut
ive
wee
ks. T
he p
rog
ram
co
mb
ines
:•
45-6
0 m
inut
es o
f p
hysi
cal a
ctiv
ity
led
by
a ce
rtifi
ed p
hysi
cal a
ctiv
ity
pro
gra
m le
ader
• 45
-60
min
utes
of
soci
ally
sti
mul
atin
g m
enta
l act
ivit
ies
faci
litat
ed b
y an
Alz
heim
er
So
ciet
y o
f Sa
skat
chew
an p
rog
ram
sta
ff a
nd v
olu
ntee
rs•
Lig
ht, h
ealt
hy r
efre
shm
ents
are
pro
vid
ed•
Cla
ss s
izes
are
lim
ited
in o
rder
to
acc
om
mo
dat
e th
e ne
eds
of
all p
arti
cip
ants
Ben
efits
to
the
ind
ivid
ual w
ith
dem
enti
a:•
Incr
ease
d c
onfi
den
ce a
nd c
om
fort
wit
h th
eir
dia
gno
sis
• In
clus
ion
in c
om
mun
ity
• Im
pro
ved
bal
ance
, mo
bili
ty, fl
exib
ility
and
ale
rtne
ss
Ben
efits
to
the
car
e p
artn
er/f
amily
/fri
end
:•
Self-
care
: an
op
po
rtun
ity
to f
ocu
s o
n th
eir
ow
n he
alth
, rat
her
than
fo
cusi
ng
excl
usiv
ely
on
the
need
s o
f th
e p
erso
n w
ith
dem
enti
a•
Ple
asur
e fr
om
see
ing
the
per
son
that
the
y ca
re f
or
enjo
ying
the
mse
lves
• M
utua
l sup
po
rt a
nd le
arni
ng f
rom
oth
er c
are
par
tner
s
Ben
efits
to
bo
th:
• Sh
arp
ened
men
tal f
unct
ioni
ng, s
om
etim
es la
stin
g t
wo
to
thr
ee d
ays
• R
educ
ed s
ense
of
iso
lati
on
• Im
pro
ved
bal
ance
, mo
bili
ty, fl
exib
ility
, str
eng
th a
nd e
ndur
ance
• Su
pp
ort
ive
envi
ronm
ents
whi
ch e
nco
urag
e ne
w f
rien
dsh
ips
wit
h o
ther
s w
ho a
re
livin
g a
sim
iliar
jour
ney
Ben
efits
to
vo
lunt
eers
, d
eliv
ery
staf
f an
d b
road
er c
om
mun
ity:
Incr
ease
d c
apac
ity
thro
ugh
exp
osu
re, t
rain
ing
and
lear
ning
fro
m o
ne a
noth
er
Co
ntri
but
ors
to
po
ster
– W
end
y Lu
cysh
yn, M
ind
s in
Mo
tio
n C
oo
rdin
ato
r, A
lzhe
imer
So
ciet
y o
f Sa
skat
chew
an, D
r. M
egan
O’C
onn
ell,
Dr.
Vani
na D
alB
ello
-Haa
s
Than
ks t
o t
he A
lzhe
imer
So
ciet
y o
f B
riti
sh C
olu
mb
ia a
nd A
lzhe
imer
So
ciet
y o
f M
anit
ob
a fo
r th
eir
sup
po
rt.
Res
earc
h
Oth
er g
oal
s o
f M
ind
s in
Mo
tio
n in
clud
e th
e re
sear
ch c
ond
ucte
d b
y M
egan
O’C
onn
ell,
Ph.
D a
nd V
anin
a D
al B
ello
-Haa
s, P
T, P
hD t
hro
ugh
the
Uni
vers
ity
of
Sask
atch
ewan
.P
erce
ived
exe
rtio
n w
as c
olle
cted
dur
ing
eac
h M
IM S
essi
on’
s w
eek
1, w
eek
3, w
eek
5,
and
wee
k 8
and
the
se d
ata
are
pre
sent
ed in
Tab
le 1
.
As
can
be
seen
, the
re is
co
nsid
erab
le b
etw
een
per
son
vari
abili
ty, b
ut, o
n av
erag
e, t
he
MIM
par
tici
pan
ts r
epo
rted
eng
agin
g in
a m
od
erat
e (i.
e., a
bo
ve 3
on
the
mo
difi
ed B
org
sc
ale
of
per
ceiv
ed e
xert
ion
scal
e) in
tens
ity
of
per
ceiv
ed e
xert
ion
(mo
der
ate
inte
nsit
y p
hysi
cal a
ctiv
ity
and
exe
rcis
e fo
r 15
0 m
inut
es a
wee
k is
the
rec
om
men
ded
do
se a
nd
freq
uenc
y).
Dat
a fr
om
Tab
le 1
reg
ard
ing
BO
RG
Per
ceiv
ed E
xert
ion
Pro
vid
ing
hel
p f
or
tod
ay
and
ho
pe
for
tom
orr
ow
for
peo
ple
aff
ecte
d
by
dem
enti
a
Tab
le 1
NM
inim
umM
axim
umM
SD
BO
RG
Wee
k 1
241.
007.
004.
461.
65B
OR
G W
eek
326
3.00
8.00
5.02
1.52
BO
RG
Wee
k 5
181.
007.
004.
981.
55B
OR
G W
eek
825
2.00
8.00
5.08
1.26
Ob
serv
atio
nal m
easu
res
of
eng
agem
ent
dem
ons
trat
ed h
igh
leve
ls o
f en
gag
emen
t ac
ross
all
ob
serv
ed s
essi
ons
(see
Tab
le 2
). Th
ese
dat
a ar
e no
tab
le f
or
thei
r co
nsis
tenc
y ac
ross
wee
ks o
f th
e M
IM s
essi
ons
, wit
h co
nsis
tent
ly h
igh
leve
ls o
f en
gag
emen
t o
bse
rved
in m
ost
do
mai
ns. T
he
exp
ress
ion
of
ple
asur
e, h
ow
ever
, dem
ons
trat
ed m
ore
ind
ivid
ual v
aria
bili
ty w
ith
mo
st e
xpre
ssin
g
ple
asur
e d
urin
g t
he a
ctiv
ity.
Tab
le 2
. Des
crip
tive
sta
tist
ics
(fre
que
ncy
in p
erce
ntag
e) o
f M
eno
rah-
Par
k E
ngag
emen
t Sc
ale
bas
ed
on
ob
serv
atio
ns o
f ea
ch p
arti
cip
ant
dur
ing
exe
rcis
e ac
ross
bo
th M
IM s
essi
ons
This
pilo
t p
rog
ram
was
mad
e p
oss
ible
by
Jam
es P
. M
aho
ney
Inst
itut
e o
f th
e F
amily
“The
em
pat
hy a
nd u
nder
stan
din
g w
itho
ut
pat
roni
zing
by
the
org
aniz
er a
nd t
he
volu
ntee
rs h
as b
een
exce
pti
ona
l…w
e su
rely
ho
pe
that
thi
s g
reat
pro
gra
m w
ill c
ont
inue
!”
All
par
tici
pan
ts w
ere
inte
rvie
wed
aft
er t
hey
com
ple
ted
w
eek
8 o
f th
eir
firs
t M
IM s
essi
on
and
dat
a w
ere
anal
yzed
th
emat
ical
ly. R
esea
rch
dat
a re
spo
nses
via
inte
rvie
w in
clud
e:
Ove
rwhe
lmin
gly
po
siti
ve a
ll w
oul
d e
nro
ll ag
ain,
but
mo
st in
terv
iew
ees
men
tio
ned
the
exe
rcis
e p
ort
ion
and
the
op
po
rtun
ity
for
soci
aliz
atio
n as
rea
sons
fo
r th
eir
po
siti
ve a
pp
rais
al.
The
exer
cise
was
men
tio
ned
m
ost
oft
en in
res
po
nse
to t
he g
ener
al q
uery
of
wha
t th
ey li
ked
mo
st
abo
ut t
he M
ind
s in
Mo
tio
n p
rog
ram
.
Man
y p
osi
tive
co
mm
ents
rev
olv
ed a
roun
d t
he t
hem
e o
f in
clus
iven
ess
and
the
‘no
n-th
reat
enin
g’ e
nvir
onm
ent
“Thi
s is
a p
rog
ram
tha
t I w
oul
d lo
ve t
o s
ee
cont
inue
d a
s it
was
a h
uge
ben
efit
to
all w
ho p
arti
cip
ated
.”
Seco
nd m
ost
oft
en r
epo
rted
and
a r
ecur
rent
the
me
thro
ugho
ut
oth
er q
uest
ions
ab
out
the
MIM
pro
gra
m w
as t
he o
pp
ort
unit
y fo
r so
cial
izat
ion:
“re
ally
like
the
ind
ivid
uals
tha
t ar
e th
ere
too
.”
Man
y m
enti
one
d t
he M
IM a
s m
eeti
ng a
so
cial
gap
in t
heir
live
s:
“and
so
cial
sup
po
rt f
rom
the
pro
gra
m t
hat
he w
oul
d n
ot
oth
erw
ise
rece
ive.
”
A n
ota
ble
min
ori
ty m
enti
one
d t
he a
cco
mm
od
atin
g n
atur
e o
f th
e M
IM
pro
gra
m a
s a
po
siti
ve (d
ue t
o p
arti
cip
ants
wit
h va
st d
iffer
ence
s in
ab
iliti
es –
bo
th in
phy
sica
l ab
ility
and
co
gni
tive
/fun
ctio
nal a
bili
ty).
Man
y p
osi
tive
co
mm
ents
rev
olv
ed a
roun
d t
he t
hem
e o
f in
clus
iven
ess
and
the
‘no
n-th
reat
enin
g’ e
nvir
onm
ent,
incl
udin
g e
xplic
it m
enti
on
of
bei
ng in
a g
roup
wit
h o
ther
s w
ho a
lso
hav
e d
emen
tia
and
wit
h o
ther
ca
re p
artn
ers
of
per
sons
dia
gno
sed
wit
h d
emen
tia.
16
RESE
ARC
H PO
STER
PRE
SENT
ATIO
N D
ESIG
N ©
201
5
ww
w.P
oste
rPre
sent
atio
ns.c
om
Backgrou
nd
Definition
of O
utreach
1.To
des
crib
e th
e de
velo
pmen
t and
impl
emen
tatio
n of
out
reac
h by
th
e Al
zhei
mer
Soc
iety
of S
aska
tche
wan
to h
ealth
pro
fess
iona
ls
who
dia
gnos
e an
d tre
at d
emen
tia (i
.e.,
fam
ily p
hysi
cian
s, g
eria
tric
spec
ialis
ts, n
urse
pra
ctiti
oner
s).
2.To
det
erm
ine
the
exte
nt to
whi
ch o
utre
ach
to h
ealth
pro
fess
iona
ls
that
dia
gnos
e an
d tre
at d
emen
tia a
chie
ves
its in
tend
ed o
bjec
tive.
3.To
det
erm
ine
why
dire
ct re
ferra
ls to
the
Alzh
eim
er S
ocie
ty h
ave
been
low
from
hea
lth p
rofe
ssio
nals
who
hav
e re
ceiv
ed o
utre
ach
from
the
Soci
ety.
Figu
re 2: Logic Mod
el fo
r Outreach to Fam
ily
Physicians, G
eriatric Spe
cialists, and
Nurse
Practitione
rs (o
r FPG
SNPs)
Doc
umen
t rev
iew
and
inte
rvie
ws
with
Firs
t Lin
kTMPr
ogra
mst
aff:
Out
reac
h to
hea
lth p
rofe
ssio
nals
who
dia
gnos
e an
d tre
at d
emen
tia
prim
arily
invo
lves
Firs
t Lin
kTMC
o-or
dina
tors
:•
mak
ing
cont
act w
ith o
ffice
and
nur
se m
anag
ers
in p
rimar
y ca
re
clin
ics
thro
ugh
visi
ts, p
hone
cal
ls, f
axes
, e-m
ails
•di
strib
utin
g re
ferra
l for
ms
and
writ
ten
info
rmat
ion
abou
t the
be
nefit
s of
refe
rral
•gi
ving
pre
sent
atio
ns to
gro
ups
of h
ealth
pro
fess
iona
ls•
conn
ectin
g w
ith h
ealth
pro
fess
iona
ls a
t con
fere
nces
and
pub
lic
even
ts
Bar
riers
that
Firs
t Lin
kTMC
o-or
dina
tors
enc
ount
er w
hen
doin
g ou
treac
h to
hea
lth p
rofe
ssio
nals
who
dia
gnos
e an
d tre
at d
emen
tia
incl
ude,
but
are
not
lim
ited
to:
•di
fficu
lty in
get
ting
face
-to-fa
ce ti
me
with
fam
ily p
hysi
cian
s,
geria
tric
spec
ialis
ts, a
nd n
urse
pra
ctiti
oner
s•
the
mov
emen
t or m
igra
tion
of fa
mily
phy
sici
ans
and
nurs
e pr
actit
ione
rs•
limite
d tim
e an
d re
sour
ces
to d
o ou
treac
h•
diffi
culty
in g
ettin
g ou
t to
rura
l are
as o
f the
pro
vinc
e
Faci
litat
ors
of o
utre
ach
to h
ealth
pro
fess
iona
ls w
ho d
iagn
ose
and
treat
dem
entia
incl
ude,
but
are
not
lim
ited
to:
•us
e of
sta
tistic
s fro
m v
ario
us s
ourc
es (e
.g.,
prev
ious
Firs
t Lin
kTM
eval
uatio
n, R
isin
g Ti
de)
•ha
ving
goo
d re
latio
nshi
ps w
ith o
ffice
man
ager
s
Surv
ey o
f fam
ily p
hysi
cian
s, g
eria
tric
spe
cial
ists
, nur
se
prac
titio
ners
who
rece
ived
out
reac
h:W
e ac
hiev
ed a
com
plet
ed s
urve
y re
spon
se ra
te o
f 79%
. Th
e re
spon
se
rate
was
the
high
est f
rom
spe
cial
ists
(100
%, n
=12/
12) a
nd n
urse
pr
actit
ione
rs (1
00%
, n=8
/8) a
nd lo
wes
t fro
m fa
mily
phy
sici
ans
(72%
, 94
/130
). F
our o
f the
118
sur
vey
resp
onde
nts
(3%
) did
not
repo
rt th
eir
prof
essi
on.
Nur
se p
ract
ition
ers
repo
rted
a gr
eate
r fam
iliarit
y w
ith th
e se
rvic
es a
nd s
uppo
rts p
rovi
ded
by th
e Al
zhei
mer
Soc
iety
than
sp
ecia
lists
and
phy
sici
ans
(see
Fig
ure
4).
Prelim
inary Re
sults
Conclusion
s
Sugg
estio
ns o
n ho
w to
less
en o
r elim
inat
e ba
rrie
rs to
refe
rral
s:Si
xty-
one
of th
e 11
8 su
rvey
resp
onde
nts
(52%
) offe
red
sugg
estio
ns
on h
ow to
less
en o
r elim
inat
e ba
rrier
s to
pat
ient
refe
rrals
. Se
ven
key
them
es e
mer
ged
from
thes
e su
gges
tions
:•
incr
ease
pub
lic’s
aw
aren
ess
and
know
ledg
e of
pro
gram
s an
d se
rvic
es•
prov
ide
info
rmat
ion
abou
t the
refe
rral p
roce
ss a
nd re
sour
ces
to
heal
th c
are
prof
essi
onal
s•
mak
e th
e re
ferra
l pro
cess
eas
y/ea
sier
•em
bed
the
refe
rral f
orm
in th
e el
ectro
nic
med
ical
reco
rd•
prov
ide
educ
atio
n ab
out d
emen
tia a
nd th
e Al
zhei
mer
Soc
iety
to
heal
th c
are
prof
essi
onal
s•
impr
ove
acce
ssib
ility
and
supp
ort t
o pa
tient
s –
espe
cial
ly in
rura
l co
mm
uniti
es a
nd s
mal
l tow
ns
•es
tabl
ish
regu
lar,
brie
f con
tact
with
an
Alzh
eim
er S
ocie
ty
repr
esen
tativ
e
Find
ings
from
a fo
cuse
d di
scus
sion
with
phy
sici
ans,
cor
rela
tiona
l an
alys
es, a
nd G
eogr
aphi
c In
form
atio
n Sy
stem
s m
appi
ng w
ill yi
eld
addi
tiona
l ins
ight
s.
References
The
prel
imin
ary
findi
ngs
sugg
est t
hat t
he c
urre
nt o
utre
ach
stra
tegy
co
uld
be im
prov
ed to
add
ress
the
barri
ers:
•en
coun
tere
d by
Firs
t Lin
kTMPr
ogra
m s
taff
whe
n do
ing
outre
ach
to
fam
ily p
hysi
cian
s, g
eria
tric
spec
ialis
ts, a
nd n
urse
pra
ctiti
oner
s•
iden
tifie
d by
fam
ily p
hysi
cian
s, g
eria
tric
spec
ialis
ts, a
nd n
urse
pr
actit
ione
rs
The
findi
ngs
will
help
the
Soci
ety
to im
prov
e its
out
reac
h st
rate
gy.
Ackn
owledgem
ents
This
stu
dy re
ceiv
ed fi
nanc
ial s
uppo
rt fro
m th
e Sa
skat
chew
an H
ealth
Res
earc
h Fo
unda
tion,
thro
ugh
the
Can
adia
n C
onso
rtium
on
Neu
rode
gene
ratio
n in
Agi
ng a
nd fr
om th
e C
olle
ge o
f Med
icin
e at
the
Uni
vers
ity o
f Sas
katc
hew
an.
1 University
of Saskatche
wan, Saskatoon
, SK, 2 A
lzheimer Society of Saskatche
wan, Regina, SK, 3 U
niversity
of V
ictoria
, Victoria
, BC
Leslie Malloy‐Weir1, PhD
, Deb
ra M
organ1, PhD
, Julie Kosteniuk
1 , Ph
D, Jo
anne
Michael
2 , Joanne
Bracken
2 , Jim
McD
avid
3 , Ph
D
Form
ative Evaluatio
n of th
e Outreach Co
mpo
nent of the
Alzh
eimer Society of
Saskatchew
an’s First LinkT
MProgram
Firs
t Lin
kTMis
an
inno
vativ
e pr
ogra
m o
f the
Alz
heim
er S
ocie
ty th
at
seek
s to
con
nect
per
sons
with
dem
entia
and
thei
r car
egiv
ers
to
supp
ort s
ervi
ces
early
in th
e di
seas
e pr
oces
s(M
cAin
ey, H
illier
, St
olee
, Har
vey,
& M
icha
el, 2
012)
. Pe
rson
s w
ith d
emen
tia a
nd th
eir
care
give
rs c
an a
cces
s th
is p
rogr
am v
ia a
nyon
e of
the
follo
win
g:•
self-
refe
rral
–co
ntac
t is
initi
ated
by
the
pers
on w
ith d
emen
tia
and/
or th
eir c
areg
iver
•di
rect
refe
rral
-a
heal
th p
rofe
ssio
nal o
btai
ns th
e pa
tient
’s o
r ca
regi
ver’s
per
mis
sion
to s
hare
thei
r inf
orm
atio
n w
ith th
e Al
zhei
mer
Soc
iety
•in
stru
cted
refe
rral
–a
heal
th p
rofe
ssio
nal m
akes
a v
erba
l re
com
men
datio
n to
the
patie
nt o
r clie
nt to
con
tact
the
Alzh
eim
er
Soci
ety
on th
eir o
wn.
In 2
011,
a fo
rmal
eva
luat
ion
of th
e Fi
rst L
inkTM
pro
gram
in th
e pr
ovin
ce o
f Sas
katc
hew
an fo
und
that
dire
ct re
ferr
als
conn
ecte
d pe
rson
s w
ith d
emen
tia a
nd th
eir c
areg
iver
s to
sup
port
serv
ices
11
mon
ths,
on
aver
age,
soo
ner t
han
self-
refe
rral
s(M
cAin
ey e
t al.,
20
12).
The
num
ber o
f dire
ct re
ferr
als
wer
e al
so fo
und
to b
e lo
wer
th
an e
xpec
ted.
This
phe
nom
enon
has
con
tinue
d de
spite
sig
nific
ant
outre
ach
effo
rts b
y th
e Al
zhei
mer
Soc
iety
of S
aska
tche
wan
to
prom
ote
the
bene
fits
of re
ferra
ls to
hea
lth p
rofe
ssio
nals
who
di
agno
se a
nd tr
eat d
emen
tia.
Figu
re 1
: Sa
skat
chew
an H
ealth
Reg
ions
Out
reac
h is
con
duct
ed
by F
irst L
inkTM
Co-
ordi
nato
rs th
at a
re
loca
ted
in s
ix o
f Sa
skat
chew
an’s
13
heal
th re
gion
s:•
Cyp
ress
•Pr
airie
Nor
th•
Prin
ce A
lber
t Pa
rkla
nd•
Reg
ina
Qu’
Appe
lle•
Sask
atoo
n•
Sun
Cou
ntry
indi
cate
s lo
catio
n of
Res
ourc
e C
entre
s in
eac
h he
alth
re
gion
Sask
atch
ewan
Hea
lth R
egio
ns (n
.d.)
Objectiv
es of Evaluation
Metho
ds
Bar
riers
to p
atie
nt re
ferr
als:
Thirt
y-tw
o pe
r cen
t of h
ealth
car
e pr
ofes
sion
als
surv
eyed
had
not
en
coun
tere
d an
y ba
rrier
s to
refe
rring
pat
ient
s to
the
Alzh
eim
er
Soci
ety.
Am
ong
thos
e re
porti
ng b
arrie
rs, t
he m
ost c
omm
on
reas
ons
wer
e la
ck o
f inf
orm
atio
n, o
r kno
wle
dge,
abo
ut th
e Al
zhei
mer
Soc
iety
(63%
, n=4
8/67
) and
lack
of f
amilia
rity
with
the
refe
rral p
roce
ss (6
1%, n
=47/
76).
Kost
eniu
k et
al.
(201
5, p
. 31)
Usi
ng a
cas
e st
udy
appr
oach
(Yin
, 200
9), w
e co
llect
ed a
nd
trian
gula
ted
data
from
mul
tiple
sou
rces
: se
mi-s
truct
ured
inte
rvie
ws
with
Firs
t Lin
kTMPr
ogra
m S
taff
(n=8
); Fi
rst L
ink-
rela
ted
docu
men
ts
(n=3
5); s
urve
y of
fam
ily p
hysi
cian
s, g
eria
tric
spec
ialis
ts, a
nd n
urse
pr
actit
ione
rs w
ho re
ceiv
ed o
utre
ach
from
the
Soci
ety
betw
een
2011
an
d 20
15 (n
=112
); an
d th
e nu
mbe
r of o
utre
ach
activ
ities
pro
vide
d by
the
Soci
ety
to, a
nd n
umbe
r of r
efer
rals
mad
e by
, fam
ily
phys
icia
ns, g
eria
tric
spec
ialis
ts, a
nd n
urse
pra
ctiti
oner
s be
twee
n 20
11 a
nd 2
015.
Qua
litat
ive
data
und
erw
ent c
onte
nt a
naly
sis.
Q
uant
itativ
e da
ta w
ere
anal
yzed
usi
ng d
escr
iptiv
e an
d in
fere
ntia
l st
atis
tics.
Qua
ntita
tive
data
wer
e al
so a
naly
zed
usin
g ge
ogra
phic
in
form
atio
n sy
stem
s m
appi
ng a
nd e
xam
ined
rela
tive
to e
xist
ing
epid
emio
logi
cal d
ata
(see
Fig
ure
3) a
nd re
gion
al p
ropo
rtion
s of
re
side
nts
aged
65
year
s an
d ol
der.
Figu
re 4
:Sur
vey
resp
onde
nts’
(N=1
14) r
epor
ted
leve
l of f
amili
arity
w
ith th
e se
rvic
es a
nd s
uppo
rts
prov
ided
by
the
Alzh
eim
er S
ocie
ty
Figu
re 3
: Pr
eval
ence
of D
emen
tia in
Sas
katc
hew
an
Prelim
inary Re
sults
Kost
eniu
k, J
. G.,
Mor
gan,
D. G
., Q
uail,
J. M
., Te
are,
G.T
., Ku
lyk, K
., O
’Con
nell,
M. E
., Ki
rk, A
., C
orss
ley,
M.,
Stew
art,
N. J
.,D
al B
ello
-Haa
s, V
., M
cBai
n, L
., M
ou, H
., Fo
rbes
, D.,
Inne
s, A
n., B
rack
en, J
., Pa
rrott,
E. (
2015
). A
Mul
ti-M
etho
d In
vest
igat
ion
of D
emen
tia a
nd R
elat
ed S
ervi
ces
in S
aska
tche
wan
: Fi
nal R
epor
t and
Rec
omm
enda
tions
. Sa
skat
oon,
Sa
skat
chew
an:
Uni
vers
ity o
f Sas
katc
hew
an.
McA
iney
, C. A
. (20
12).
‘Thr
owin
g a
lifel
ine’
: th
e ro
le o
f Firs
t Lin
kTM
in e
nhan
cing
sup
port
for i
ndiv
idua
ls w
ith d
emen
tia a
nd
thei
r car
egiv
ers.
Neu
rode
gen.
Dis
. Man
age.
, 2(6
), 62
3-63
8.
Sask
atch
ewan
Hea
lth R
egio
ns (n
.d.).
Map
. R
etrie
ved
from
: http
://sa
sksu
rger
y.ca/
map
.htm
l
Yin,
R. K
. (20
09).
Cas
e st
udy
rese
arch
. D
esig
n an
d m
etho
ds.
Four
th e
ditio
n. T
hous
and
Oak
s, C
A: S
age
Publ
icat
ions
, In
c.
Prev
alen
t cas
es
wer
e id
entif
ied
in
one
of fo
ur
adm
inis
trativ
e he
alth
da
taba
ses(
Hos
pita
l D
isch
arge
Abs
tract
s,
Phys
icia
n Se
rvic
e C
laim
s, P
resc
riptio
n D
rug,
and
RAI
-MD
S,
i.e.,
Long
-Ter
m
Car
e).
Implications of the
Research
17
!"#$
$%&'%(
)*&)+
,+#
$-+%
./0%
)1%.
%&0*
#)!#
+%:
!!F
ewer
hig
hly
train
ed s
taff
& d
emen
tia-s
peci
fic s
ervi
ces
!!G
reat
er tr
avel
dis
tanc
e to
spe
cial
ists
in u
rban
cen
tres
!!L
ack
of a
cces
s to
con
tinui
ng e
duca
tion
for h
ealth
pro
vide
rs
S TU
DY
OB
JEC
TIVE
: To
deve
lop/
adap
t, im
plem
ent,
and
eval
uate
a
Rur
al P
rimar
y H
ealth
Car
e D
emen
tia M
odel
bas
ed o
n 7
elem
ents
of
com
preh
ensi
ve p
rimar
y he
alth
car
e fo
r dem
entia
(Am
inza
deh
et
al, 2
012)
& C
anad
ian
cons
ensu
s gu
idel
ines
(CC
CD
TD4)
!!IN
NER
SET
TIN
G E
NA
BLE
RS:
tea
m d
esire
to im
prov
e ca
re (e
g, e
arlie
r dia
gnos
is),
fam
iliar
ity w
ith o
ther
chr
onic
dis
ease
dec
isio
n to
ols,
ava
ilabi
lity
of m
ultip
le
disc
iplin
es, c
ultu
re o
f qua
lity
impr
ovem
ent,
expe
rtise
of E
MR
tech
nica
l sup
port
to c
reat
e E
MR
ver
sion
of f
low
she
ets
that
can
be
scal
ed u
p re
gion
-wid
e.
!!IN
NER
SET
TIN
G B
AR
RIE
RS:
lim
ited
time
to m
eet,
chal
leng
es in
intro
duci
ng n
ew
wor
k pr
oces
ses
and
tool
s in
bus
y pr
actic
e, b
alan
cing
nee
d fo
r evi
denc
e-ba
sed
tool
s an
d qu
ick
user
-frie
ndly
tool
s !! O
UTE
R S
ETTI
NG
EN
AB
LER
S: re
gion
al le
ader
ship
sup
port,
tele
heal
th s
yste
m
!!P
RO
CES
S EN
AB
LER
S: s
trong
eng
agem
ent o
f cha
mpi
ons
on te
am a
nd fo
rmal
le
ader
s, in
crem
enta
l im
plem
enta
tion/
adap
tatio
n of
EM
R d
ecis
ion
supp
ort t
ools
!!P
RO
CES
S B
AR
RIE
RS:
long
dis
tanc
e of
rese
arch
ers
from
team
(820
km
/roun
d tri
p)
!!C
omm
unity
-bas
ed p
artic
ipat
ory
rese
arch
and
5-s
tep
adap
tatio
n m
odel
( McK
lero
y 20
06, L
ee 2
008,
Jan
sen
2013
, Cab
assa
201
4)
!!P
roce
ss e
valu
atio
n of
impl
emen
tatio
n ba
rrie
rs &
faci
litat
ors
(Con
solid
ated
Fra
mew
ork
for I
mpl
emen
tatio
n R
esea
rch,
Dam
schr
oder
200
9)
CCN
A T
eam
20
Rura
l D
evel
opin
g ru
ral d
emen
tia
care
bes
t pra
ctic
es
in
pri
mar
y he
alth
car
e te
ams:
A c
omm
unit
y-ba
sed
appr
oach
D
ebra
Mor
gan,
Julie
Kos
teni
uk, D
alla
s Se
itz, M
egan
O’C
onne
ll, A
ndre
w K
irk, N
orm
a St
ewar
t, Ja
yna
Hol
royd
-Led
uc
!234
564!"#$
%&'()*&+',-
./'/0(1'"
!!5
8% ru
ral (!1
0,00
0)
!!1
.8 p
erso
ns/k
m2
!!1
5% "
age
65
year
s !!7
prim
ary
heal
th c
are
team
s !!S
tarti
ng w
ith o
ne te
am
(Kip
ling)
then
sca
le u
p
Liv
e, W
ork
, P
lay
Ple
ase S
ele
ct a C
om
munity to B
egin
Maps
(h
ttp
://m
ap
s.g
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gle
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ap
s?
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KIP
LIN
G P
RIM
ARY
HEA
LTH
CA
RE
TEA
M
!!5
hou
r driv
e fro
m S
aska
toon
(410
km
one
way
) !!3
fam
ily p
hysi
cian
s, 1
Nur
se P
ract
ition
er,
1
Occ
upat
iona
l The
rapi
st, 2
Hom
e C
are
nurs
es
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)H#:
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J=G)
K8LK
M)
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egio
nal S
teer
ing
Gro
up
esta
blis
hed:
17
mee
tings
to d
ate
!!R
egio
nal N
eeds
Ass
essm
ent:
repo
rt re
leas
ed S
ept 2
016
!!Im
plem
entin
g &
ada
ptin
g de
cisi
on s
uppo
rt to
ols
( Prim
ary
Car
e –
Dem
entia
Ass
essm
ent a
nd
Trea
tmen
t Alg
orith
m [P
C-D
ATA
] (S
eitz
, PI)
and
embe
ddin
g PC
-D
ATA
visi
t flo
w s
heet
s in
EM
R
!!Im
plem
entin
g te
am–b
ased
co
llabo
rativ
e ca
re s
trate
gies
(e
g, te
am c
ase
conf
eren
ces)
!236
<NAC23
AO)6"p
artic
ipat
ory
appr
oach
allo
ws
ongo
ing
adap
tatio
n in
col
labo
ratio
n w
ith
com
mun
ity p
artn
ers.
We
have
iden
tifie
d im
plem
enta
tion
enab
lers
and
bar
riers
that
w
ill in
form
sca
ling
up to
oth
er te
ams
in S
un C
ount
ry H
ealth
Reg
ion
18
Are
targ
ets o
f dep
ress
ion-
rela
ted
drug
sus
eful
dia
gnos
tics f
or A
lzhe
imer
Dis
ease
?Je
nnife
r N
.K. N
yark
o1 ;M
aa O
. Qua
rtey
1 ; P
aul R
. Pen
ning
ton1 ;
Gle
n B
. Bak
er2 ;
Dar
rell
D. M
ouss
eau1 .
1: C
ell S
igna
lling
Lab
orat
ory,
Dep
artm
ent o
f Psy
chia
try,
Uni
vers
ity o
f Sas
katc
hew
an;
2: N
euro
chem
ical
Res
earc
h U
nit,
Dep
artm
ent o
f Psy
chia
try,
Uni
vers
ity o
f Alb
erta
.
Con
clus
ions
:•S
ERT
geno
typi
ngdo
esno
tcor
resp
ond
toei
ther
SERT
prot
ein
expr
essi
onor
5-H
Ttu
rnov
er.
•Diff
eren
ces
inth
ele
vels
ofA
D-r
elat
edAβ
and
p3fr
agm
ents
betw
een
hom
ozyg
ous
(l/lo
rs/s
)and
hete
rozy
gous
(i.e.
l/s)i
ndiv
idua
lsco
uld
bein
dica
ting
anun
antic
ipat
edfu
nctio
nfo
rthe
SERT
prot
ein
inAβ
pept
ide
trans
port
orpl
aque
form
atio
n.
Ack
now
ledg
men
ts:
DD
Mis
the
Sask
atch
ewan
Res
earc
hC
hair
inAl
zhei
mer
’sdi
seas
ean
dre
late
dde
men
tiath
atis
co-f
unde
dby
the
Alz
heim
erSo
ciet
yof
Sask
atch
ewan
and
the
Sask
atch
ewan
Hea
lthR
esea
rch
Foun
datio
n.
Fig.
4. S
ER
Tge
noty
ping
doe
s not
alig
n w
ith se
roto
nin
turn
over
Cor
tical
(left)
and
hipp
ocam
pal(
right
)sam
ples
wer
ean
alyz
edby
HPL
Cfo
rlev
elso
fse
roto
nin
(5-H
T)an
dits
prim
ary
met
abol
ite,5
-HIA
A.T
hera
tioof
5-H
IAA
to5-
HT
isus
edas
anin
dex
of5-
HT
turn
over
(usa
gean
din
activ
atio
n).
Ther
ew
asno
corr
elat
ion
betw
een
5-H
Ttu
rnov
eran
dSE
RTge
noty
ping
inei
ther
regi
on.
Fig.
5.SE
RT
geno
typi
ngdo
esno
talig
nw
ithA
D-r
elat
edAβ
orp3
spec
ies.
The
leve
lsof
the
inso
lubl
e(p
laqu
e-as
soci
ated
)A
D-r
elat
edAβ
orp3
pept
ide
frag
men
tsar
ehi
gher
inth
eA
Dsa
mpl
esre
gard
less
ofSE
RTge
noty
pe.U
nexp
ecte
dly,
the
leve
lsof
the
pept
ides
wer
efa
rm
ore
varie
din
cont
rol
indi
vidu
als
with
ahe
tero
zygo
usSE
RTge
noty
pe,t
han
inei
ther
ofth
eho
moz
ygou
scon
trols
ampl
es.
Cor
tical
Sam
ples
Hip
poca
mpa
l Sam
ples
Fig.
3:SE
RT
prot
ein
leve
lsdo
nota
lign
with
SER
Tge
noty
ping
The
expr
essi
onof
the
SERT
prot
ein
was
dete
rmin
edby
Wes
tern
blot
ting
ofce
llly
sate
san
dde
nsito
met
rican
alys
is.S
ERT
prot
ein
expr
essi
ondi
dno
tdiff
erbe
twee
nC
ontro
l(C
)or
AD
sam
ples
,reg
ardl
esso
fgen
otyp
e(i.
e.l/l
,l/s
ors/
s).
SER
T ex
pres
sion
in C
orte
xSE
RT
expr
essi
on in
Hip
poca
mpu
s
The
dist
ribut
ion
ofth
eal
lelic
varia
nts
(i.e.
s/s,
l/s/
and
l/l)
was
asex
pect
edin
the
cont
rol(
CTL
)aut
opsi
edbr
ain
sam
ples
;how
ever
,we
did
notf
ind
agr
eate
rpro
porti
onof
the
s/s
geno
type
inth
eEa
rly-O
nset
AD
(EO
AD
)or
Late
-Ons
etA
D(L
OA
D)
sam
ples
..
Fig.
2: S
ER
TG
enot
ypin
g of
Hum
an A
utop
sied
Tis
sue
Gen
omic
DN
Aw
asex
tract
edfr
omau
tops
ied
cere
bella
rsa
mpl
es.
Stan
dard
PCR
was
used
toam
plify
the
regi
onof
the
SERT
prom
oter
that
cont
ains
the
40bp
sequ
ence
(hig
hlig
hted
inre
din
Fig.
1).T
hePC
Rre
actio
nsw
ere
then
visu
aliz
edun
derU
Vlig
htto
dete
rmin
ew
heth
erth
esa
mpl
eco
ntai
nson
lyth
elo
ngal
lele
(l/l:
419
bp),
the
shor
talle
le(s
/s:3
75bp
)orb
oth
(l/s)
.
400
bp35
0 bp
450
bp
Intr
oduc
tion
Bac
kgro
und:
Neu
rons
com
mun
icat
eus
ing
chem
ical
mes
seng
ers
such
asse
roto
nin.
Thes
ech
emic
alm
esse
nger
s,re
ferr
edto
asne
urot
rans
mitt
ers,
exer
tth
eire
ffect
sin
gaps
(syn
apse
s)be
twee
nth
ece
lls.O
nce
sero
toni
nha
sex
erte
dits
effe
ct,i
tcan
bere
mov
edfr
omth
esy
naps
eby
apr
otei
nca
lled
the
sero
toni
ntra
nspo
rter(
SERT
).
Lite
ratu
re:
The
gene
for
SERT
has
apr
omot
erre
gion
that
tells
the
cell
how
muc
hof
the
trans
porte
rto
mak
e.Th
ere
are
two
form
s(a
llele
s)of
the
prom
oter
and
peop
leha
vetw
oco
pies
ofth
eSE
RTge
ne;o
nefr
omea
chpa
rent
.A
proc
ess
calle
dge
noty
ping
can
dete
rmin
ew
heth
eran
indi
vidu
alha
stw
oco
pies
ofth
esh
orta
llele
(hom
ozyg
ous
for
s/s)
,tw
oco
pies
ofth
elo
ngal
lele
(hom
ozyg
ous
for
l/l)
orha
veon
eco
pyea
ch(h
eter
ozyg
ous:
l/s).
The
shor
tal
lele
isth
ough
tto
incr
ease
the
risk
ofco
gniti
vede
clin
ean
dA
lzhe
imer
'sD
isea
se(A
D).
The
long
-or
shor
t-al
lele
isth
ough
tto
incr
ease
-or
decr
ease
-SE
RTpr
otei
nex
pres
sion
.Hav
ing
aco
pyof
both
alle
les
isth
ough
tto
lead
toin
term
edia
tele
vels
ofSE
RTex
pres
sion
.
Res
earc
hPl
an:
We
anal
yzed
auto
psie
dhu
man
brai
ntis
sue
(fro
mco
ntro
ldo
nors
asw
ell
asfr
omA
Dpa
tient
s)to
dete
rmin
ew
heth
era
spec
ific
SERT
geno
type
alig
ned
with
adi
agno
siso
fAD
.
Fig.
1: S
ER
Tal
lele
s and
the
Sero
toni
n Sy
naps
e
http
://w
ww.
bio.
davi
dson
.edu
/cou
rses
/gen
omic
s/20
03/m
ccor
d/5-
htt.h
tml
SE
RT
long
alle
le
SE
RT
shor
t alle
le
(top)
Adi
agra
mde
pict
ing
the
SERT
gene
,whi
chin
clud
esth
epr
omot
eran
dth
etra
nsla
ted
(cod
ing)
regi
on.T
helo
ngal
lele
cont
ains
ava
riabl
ere
gion
(red
rect
angl
e)w
hich
can
incl
ude
43ex
traba
sepa
irs(g
reen
rect
angl
e).
The
arro
ws
repr
esen
tpr
imer
sth
atfla
nkth
isre
gion
and
allo
wus
tois
olat
eit
usin
gpo
lym
eras
ech
ain
reac
tion
(PC
R).
This
isth
eap
proa
chus
edfo
rSE
RTge
noty
ping
(see
Fig.
2).
(rig
ht)T
helo
ngal
lele
tells
the
cell
tom
ake
mor
eSE
RTm
RN
Aan
dul
timat
ely
mor
eSE
RTpr
otei
n.Th
eSE
RTpr
otei
nhe
lps
the
cell
tota
keup
any
sero
toni
nth
atm
ight
bein
the
syna
pse.
19
Stud
y 1
Expl
orin
g in
tere
st a
nd g
oals
for v
ideo
conf
eren
cing
del
iver
ed
cogn
itive
reha
bilit
atio
n w
ith ru
ral i
ndiv
idua
ls w
ith m
ild
cogn
itive
impa
irmen
t or d
emen
tiaR
ache
l Bur
ton1
& M
egan
E. O
’Con
nell1
1 D
epar
tmen
t of P
sych
olog
y, U
nive
rsity
of S
aska
tche
wan
RR
MC
Fun
ding
and
in-k
ind
supp
ort i
s ge
nero
usly
pro
vide
d by
:
Stud
y 2
Stud
y 3
INTR
OD
UC
TIO
NTe
le-re
habi
litat
ion
isa
deve
lopi
ngfie
ldw
ithth
epr
omis
eof
incr
easi
ngth
eac
cess
ibilit
yof
spec
ializ
edin
terv
entio
nssu
chas
cogn
itive
reha
bilit
atio
n.Th
epr
opos
edre
sear
chw
illbu
ildon
prev
ious
rese
arch
exam
inin
gco
gniti
vere
habi
litat
ion
deliv
ered
in-p
erso
nto
indi
vidu
als
with
dem
entia
,rem
otel
yde
liver
edin
terv
entio
nsfo
rin
divi
dual
sw
ithde
men
tia,a
sw
ella
sre
mot
ely
deliv
ered
cogn
itive
reha
bilit
atio
nde
liver
edto
indi
vidu
als
with
TBIs
.To
date
,rem
otel
yde
liver
edco
gniti
vere
habi
litat
ion
forp
erso
nsw
ithde
men
tiaha
sno
tbee
nsy
stem
atic
ally
stud
ied.
Purp
ose
•To
exp
lore
inte
rest
in v
ideo
conf
eren
cing
deliv
ered
cog
nitiv
e re
habi
litat
ion
•To
exp
lore
the
type
s of
goa
ls th
at a
re s
et b
y in
divi
dual
s w
ith c
ogni
tive
impa
irmen
ts•
To c
ompa
re th
e cl
inic
al c
hara
cter
istic
s of
indi
vidu
als
who
resp
onde
d to
a q
uest
ionn
aire
ask
ing
abou
t co
gniti
ve re
habi
litat
ion
to th
ose
who
did
not
Met
hod
•Pa
rtici
pant
s re
crui
ted
from
Uni
vers
ity o
f Sa
skat
chew
an’s
Rur
al a
nd R
emot
e M
emor
y C
linic
(R
RM
C)
•61
clin
ic p
atie
nts
with
dia
gnos
es o
f aM
CI o
r de
men
tia d
ue to
AD
and
fam
ily c
areg
iver
s in
vite
d to
pa
rtici
pate
•Q
uest
ionn
aire
s co
mpl
eted
by
10 p
atie
nts
and
15
fam
ily c
areg
iver
s•
Ever
yday
Mem
ory
Que
stio
nnai
re (E
MQ
)R
esul
ts•
The
resp
onde
rs (N
= 25
) wer
e si
mila
r to
non-
resp
onde
rs in
sev
erity
, dep
ress
ion,
and
car
egiv
er
burd
en•
Of t
he re
spon
ders
, 80%
wer
e in
tere
sted
in
vide
ocon
fere
ncin
g de
velo
ped
treat
men
t •
A th
emat
ic a
naly
sis
code
d 95
% o
f res
pons
es a
s am
enab
le to
cog
nitiv
e re
habi
litat
ion.
Par
ticip
ants
’ go
als
wer
e fo
cuse
d on
mem
ory,
hou
seho
ld a
ctiv
ities
, ot
her c
ogni
tive
dom
ains
, rec
reat
ion,
and
hig
her o
rder
ta
sks
Purp
ose
•To
ext
end
prev
ious
rese
arch
that
has
exa
min
ed th
e re
latio
nshi
p be
twee
n IA
DL,
dem
ogra
phic
/ clin
ical
va
riabl
es, a
nd c
ogni
tive
varia
bles
incl
udin
g ex
ecut
ive
func
tion
Met
hod
•40
3 co
nsec
utiv
e re
ferra
ls R
RM
C•
No
cogn
itive
impa
irmen
t (n
= 75
), M
CI (
n=
75),
dem
entia
due
to A
lzhe
imer
’s d
isea
se (n
= 13
9), o
r no
n-AD
dem
entia
(n =
114
)R
esul
ts•
Ora
l flu
ency
: In
step
1, a
ge, e
duca
tion
and
MM
SE -
R2=
0.26
, F(3
, 247
) = 2
8.62
, p<
0.00
1. In
ste
p 2,
de
laye
d m
emor
y, c
ontro
lled
oral
flue
ncy
(FAS
), de
pres
sion
and
apa
thy
-R2
= 0.
41,
F(7
, 237
) =
23.3
8, p
< 0.
001
(an
addi
tiona
l 14.
6% o
f var
ianc
e ac
coun
ted
for i
n FA
Q)
•Tr
ail M
akin
g Te
st (T
MT-
B): T
he a
dditi
on o
f TM
T-B,
de
laye
d m
emor
y, d
epre
ssio
n an
d ap
athy
lead
to a
si
gnifi
cant
incr
emen
t in
R2 ,
and
an a
dditi
onal
16.
6%
of v
aria
nce
acco
unte
d fo
r in
FAQ
•St
roop
: The
add
ition
of S
troop
, del
ayed
mem
ory,
de
pres
sion
and
apa
thy
lead
to a
sig
nific
ant i
ncre
ase
in R
2 , an
d an
add
ition
al 2
0.1%
of t
he v
aria
nce
in
FAQ
was
acc
ount
ed fo
r
KEY
MES
SAG
EC
ogni
tive
reha
bilit
atio
n fo
cuse
d on
mem
ory
is
of m
ost i
nter
est t
o pe
rson
s an
d ca
regi
vers
, and
m
ost r
ural
fam
ilies
wer
e in
tere
sted
in
vide
ocon
fere
ncin
g. V
ideo
conf
eren
ced
reha
bilit
atio
n w
as s
imila
r to
in-p
erso
n re
habi
litat
ion.
Des
pite
a fo
cus
on m
emor
y fo
r re
habi
litat
ion,
exe
cutiv
e fu
nctio
n ap
pear
s to
hav
e m
ost r
elat
ion
with
dai
ly fu
nctio
n.
Purp
ose
•C
ase
stud
yM
etho
d•
‘Alic
e’ a
nd ‘A
ndre
w’ r
epor
ted
a di
agno
sis
of d
emen
tia
due
to A
D.
•Sc
ores
< 1
stpe
rcen
tile
on te
sts
of m
emor
y.
•G
oal t
o in
crea
se A
lice’
s kn
owle
dge
and
reco
llect
ion
of m
ajor
mile
ston
es, a
ccom
plis
hmen
ts a
nd
rela
tions
hips
in h
er li
fe.
•Al
ice
and
Andr
ew c
ompi
led
an a
lbum
with
ph
otog
raph
s an
d m
emen
tos
that
repr
esen
ted
her
high
light
s.
•Fa
mily
pho
tos
•C
hild
hood
aw
ards
•D
iplo
mas
•R
etire
men
t par
ty p
hoto
s•
Vaca
tion
phot
os•
Ten
wer
e ch
osen
, and
trai
ned
with
spa
ced-
retri
eval
an
d cu
ing.
R
esul
ts
20
Stud
y 1
Iden
tity
and
Car
egiv
er B
urde
n in
Dem
entia
:A
n Ev
alua
tion
of T
eleh
ealth
Rem
inis
cenc
e fo
r Inf
orm
al C
areg
iver
sJo
e En
right
1 &
Meg
an E
. O’C
onne
ll11 D
epar
tmen
t of P
sych
olog
y, U
nive
rsity
of S
aska
tche
wan
Ref
eren
ces:
Alea
, N. &
Blu
ck, S
. (20
07).
I’ll k
eep
you
in m
ind:
the
intim
acy
func
tion
of
auto
biog
raph
ical
mem
ory.
App
lied
Cog
nitiv
e P
sych
olog
y, 2
007,
8,1
091-
1111
.
Blie
szne
r, R
. & S
hiffl
ett,
P.A.
(199
0). T
he e
ffect
s of
Alz
heim
er’s
dis
ease
on
clos
ere
latio
nshi
ps b
etw
een
patie
nts
and
care
give
rs. F
amily
Rel
atio
ns, 3
9, 5
7–62
.
Mor
ris, L
. W.,
Mor
ris, R
. G.,
& Br
itton
, P. G
. (19
88).
The
rela
tions
hip
betw
een
mar
ital i
ntim
acy,
per
ceiv
ed s
train
and
dep
ress
ion
in s
pous
e ca
re g
iver
s of
de
men
tia s
uffe
rers
. Brit
ish
Jour
nal o
f Med
ical
Psy
chol
ogy,
61,
231
–236
.
RR
MC
Fun
ding
and
in-k
ind
supp
ort i
s ge
nero
usly
pro
vide
d by
:
Stud
y 2
Stud
y 3
INTR
OD
UC
TIO
NIn
form
alca
regi
vers
’per
cept
ion
ofid
entit
ych
ange
/loss
inth
eir
care
-par
tner
with
dem
entia
isan
ecdo
tally
linke
dto
loss
ofin
timac
y,w
hile
decr
ease
din
timac
yan
dqu
ality
ofth
eca
regi
ver/p
artn
erre
latio
nshi
pis
asso
ciat
edw
ithgr
eate
rcar
egiv
erbu
rden
(Blie
szne
r&Sh
iffle
tt,19
90;M
orris
etal
.,19
88).
Aco
nnec
tion
betw
een
perc
eive
did
entit
yan
dbu
rden
isfu
rther
impl
ied
byth
epo
tent
ialb
enef
itof
rem
inis
cenc
eth
erap
yfo
rca
regi
vers
,an
dlit
erat
ure
onre
min
isce
nce
(Ale
a&
Bluc
k,20
07).
Des
pite
dem
onst
rate
dbe
nefit
for
pers
ons
with
dem
entia
,su
ppor
tfor
rem
inis
cenc
ew
ithca
regi
vers
has
been
equi
voca
l,th
ough
itis
uncl
eara
sto
why
.
Purp
ose
•To
em
piric
ally
exa
min
e th
e re
latio
nshi
p be
twee
n in
form
al c
areg
iver
s’ p
erce
ptio
n of
iden
tity
chan
ge
in th
eir c
are-
partn
er w
ith d
emen
tia, t
heir
rela
tions
hip,
and
the
perc
eptio
n of
bur
den
in
prov
idin
g ca
re•
To e
stab
lish
supp
ort f
or th
e pr
opos
ed m
odel
of
iden
tity
and
care
give
r bur
den
•To
det
erm
ine
the
degr
ee to
whi
ch th
e ca
regi
ver
curre
ntly
per
ceiv
es th
e pe
rson
with
dem
entia
’s
iden
tity
as c
hang
ed re
lativ
e to
thei
r pre
mor
bid
self
Met
hod
•C
ross
-sec
tiona
l cor
rela
tiona
l des
ign
•R
ecru
ited
58 p
artic
ipan
ts fr
om th
e U
nive
rsity
of
Sask
atch
ewan
’s R
ural
and
Rem
ote
Mem
ory
Clin
ic (R
RM
C)
•Q
uest
ionn
aire
s:•
Zarit
Burd
en In
terv
iew
(ZBI
)•
Cha
nge
in id
entit
y ra
ting
scal
e•
Burn
s R
elat
ions
hip
Satis
fact
ion
Scal
e (B
RSS
)•
Clin
ical
Dem
entia
Rat
ing
–Su
m o
f Box
ed
(CD
R-S
OB)
Res
ults
•C
areg
iver
s’ p
erce
ived
iden
tity
chan
ge in
thei
r ca
re-p
artn
er w
ith d
emen
tia s
igni
fican
tly p
redi
cted
ca
regi
ver b
urde
n us
ing
SEM
Purp
ose
•To
est
ablis
h w
heth
er e
quiv
alen
cy in
del
iver
y m
ode
acro
ss
grou
ps, s
peci
fical
ly in
-per
son
vers
us T
eleh
ealth
del
iver
y vi
a vi
deoc
onfe
renc
ing,
exi
sted
for b
oth
the
sing
le s
essi
on
rem
inis
cenc
e ac
tivity
and
con
trol c
ondi
tions
, res
pect
ivel
y.
•To
eva
luat
e ef
ficac
y of
the
rem
inis
cenc
e ac
tivity
ver
sus
the
cont
rol
•To
gai
n in
sigh
t int
o pa
rtici
pant
car
egiv
ers’
nat
ural
re
min
isci
ng b
ehav
iors
and
exp
erie
nce,
and
als
o th
eir
expe
rienc
e of
par
ticip
atin
g in
the
faci
litat
ed re
min
isce
nce
activ
ity
Met
hod
•40
info
rmal
car
egiv
ers
recr
uite
d fro
m R
RM
C•
Ran
dom
ly a
ssig
ned
care
give
rs to
resp
ectiv
e in
-per
son
or
Tele
heal
th, c
ontro
l, or
Rem
inis
cenc
e gr
oups
(2x2
des
ign)
•6
DVs
mea
sure
for 4
gro
ups:
•Pe
rcei
ved
iden
tity
chan
ge m
easu
res
(SID
Q a
nd id
entit
y ch
ange
ratin
g sc
ale)
•Sc
ores
on
intim
acy
mea
sure
s of
clo
sene
ss a
nd w
arm
th
(PAI
R a
nd S
MD
sca
les)
•C
urre
nt re
latio
nshi
p qu
ality
mea
sure
(BR
SS s
core
s)•
Car
egiv
er b
urde
n (Z
BI s
core
)R
esul
ts•
No
effe
ct o
f the
Rem
inis
cenc
e ac
tivity
on
iden
tity
chan
ge,
intim
acy,
qua
lity
of re
latio
nshi
p, o
r bur
den
was
obs
erve
d •
Qua
litat
ivel
y, m
ost c
areg
iver
s re
porti
ng a
pos
itive
ex
perie
nce,
but
cle
ar s
ubgr
oups
wer
e ev
iden
t whe
re
rem
inis
cenc
e w
as b
itter
swee
t for
som
e
Purp
ose
•To
exa
min
e th
e fe
asib
ility
and
acce
ptab
ility
of
spec
ific
Tele
heal
th p
rogr
amm
ing
•To
eva
luat
e fe
asib
ility
from
the
serv
ice
prov
ider
or
rese
arch
er s
ide
Met
hod
•Pa
rtici
pant
s fro
m S
tudy
2 w
ho p
artic
ipat
ed in
the
rem
inis
cenc
e ac
tivity
(n=
20)
•Q
uest
ionn
aire
•O
pen
ende
d an
d ra
ting
scal
ed q
uest
ions
re
gard
ing
thei
r exp
erie
nce
and
satis
fact
ion
with
th
e in
terv
entio
n pr
oces
s an
d m
ode
of d
eliv
ery
•15
car
egiv
ers
who
par
ticip
ated
in th
e re
sear
ch
proj
ect o
ver T
eleh
ealth
vid
eoco
nfer
enci
ng
com
plet
ed th
e Te
lehe
alth
Sat
isfa
ctio
n Sc
ale
durin
g a
follo
w-u
p te
leph
one
inte
rvie
wR
esul
ts•
Goo
d fe
asib
ility
for T
eleh
ealth
del
iver
y, in
clud
ing
cons
ider
able
trav
el s
avin
gs a
nd s
atis
fact
ion
with
th
e m
ediu
m
KEY
MES
SAG
EId
entif
ying
and
und
erst
andi
ng fa
ctor
s af
fect
ing
care
give
r bur
den
is c
ruci
al
tow
ards
dev
elop
men
t of e
ffect
ive
inte
rven
tion.
Per
ceiv
ed id
entit
y ch
ange
ap
pear
s to
be
one
poss
ible
fact
or in
m
ultif
acto
rial p
redi
ctio
n of
car
egiv
er b
urde
n,
but r
emin
isce
nce
dem
onst
rate
d no
effe
ct o
n bu
rden
. Tel
ehea
lth p
rove
d to
be
a pr
actic
al
and
acce
ptab
le fo
rmat
for r
ural
ser
vice
de
liver
y an
d da
ta c
olle
ctio
n.
21
Rur
al/R
emot
e an
d In
dige
nous
old
er a
dults
are
vul
nera
ble
due
to
rest
ricte
d ac
cess
to lo
cal s
uppo
rts &
ser
vice
s an
d ar
e, th
eref
ore,
the
quin
tess
entia
l end
-use
rs fo
r AG
E-W
ELL
tech
nolo
gies
Wor
ries
abou
t Mai
ntai
ning
Inde
pend
ence
of R
ural
/Rem
ote
Old
er A
dults
: Opp
ortu
nitie
s fo
r Tec
hnol
ogy
Dev
elop
men
tO
’Con
nell,
M. E
.1*, G
ould
, B.1 ,
Sce
rbe,
A.1 ,
Mor
gan,
D.1 ,
, C
arte
r, J.
1 , Bo
uras
sa, C
.2,3 ,
Jack
lin, K
.4 , W
arry
, W.5
*meg
an.o
conn
ell@
usas
k.ca
One
goal
ofAG
E-W
ELL’
sR
RIT
E:R
ural
/Rem
ote
Indi
geno
usTe
chno
logy
need
sEx
plor
atio
nis
toas
sist
inth
ede
velo
pmen
tof
AGE-
WEL
Lte
chno
logi
esth
atar
ere
leva
ntto
the
rura
l/rem
ote
user
,in
form
atio
ncr
itica
lto
help
over
com
eba
rrier
sto
the
adop
tion
ofte
chno
logi
es(M
elen
hors
t,R
oger
s&
Bouw
huis
,20
06;
Con
ci,P
iane
si&
Zanc
anar
o,20
09).
The
curre
ntst
udy
expl
ored
the
user
need
sof
rura
l/rem
ote
dwel
ling
olde
rad
ults
thro
ugh
brie
fint
ervi
ew.
31
%de
nied
any
wor
ries
asso
ciat
edw
ithag
ing.
23
%re
porte
dw
orrie
sre
latin
gto
agin
gin
the
cont
ext
ofge
ogra
phic
isol
atio
nan
dla
ckof
acce
ssib
lese
rvic
es.
18
% re
porte
d ge
nera
l anx
iety
abo
ut
inde
pend
ence
, tak
ing
care
of t
heir
hom
e, a
nd m
ovin
g in
to a
ssis
ted
or
resi
dent
ial l
ivin
g.
Rem
aini
ng c
ateg
orie
s in
clud
e:
•Ph
ysic
al d
eclin
es in
adv
ance
d ag
ing
(11%
) •
Fina
nces
(8%
) •
Neu
rolo
gica
l or m
enta
l hea
lth
cond
ition
s (5
%)
•Ph
ysic
al m
obilit
y re
stric
tions
(3
%)
•‘O
ther
’ (2%
)
Pa
rtici
pant
s w
ere
recr
uite
d fro
m
rand
omly
sel
ecte
d te
leph
one
num
bers
(la
nd li
nes
and
cell
phon
es) l
iste
d fo
r pe
rson
s re
sidi
ng o
utsi
de m
etro
polit
an
area
s of
SK,
and
wer
e pr
edom
inan
tly
rura
l/rem
ote
(mos
t fro
m s
mal
ler c
ente
rs).
62
1 ru
ral/r
emot
e se
nior
s w
ere
recr
uite
d (M
age
= 71
.5; S
D=
8.4;
rang
e 60
-102
ye
ars
old)
.
463
resp
onde
d to
an
open
-end
ed
ques
tion
rega
rdin
g th
eir ‘
wor
ries’
abo
ut
mai
ntai
ning
inde
pend
ence
as
they
ad
vanc
ed in
age
, and
them
es w
ere
anal
yzed
.
Thes
e da
ta s
ugge
st d
evel
opin
g te
chno
logy
that
miti
gate
s ge
ogra
phic
is
olat
ion
and
incr
ease
s ac
cess
ibilit
y of
ser
vice
s w
ill be
crit
ical
for
rura
l/rem
ote
seni
ors
1 5
2
3
4
Con
ci, M
., Pi
anes
i, F.
& Z
anca
naro
, M. (
2009
.) U
sefu
l, so
cial
and
enj
oyab
le: M
obile
pho
ne a
dopt
ion
by
olde
r peo
ple.
Hum
an-C
ompu
ter I
nter
actio
n –
INTE
RA
CT
2009
. Lec
ture
Noe
s in
Com
pute
r Sci
ence
,572
6,
63-7
6.M
elen
hors
t, A.
S.,
Rog
ers,
W.A
., &
Bouw
huis
, D.G
. (20
06).
Old
er a
dults
’ mot
ivat
ed c
hoic
e fo
r te
chno
logi
cal i
nnov
atio
n: E
vide
nce
for b
enef
it-dr
iven
sel
ectiv
ity. P
sych
olog
y an
d A
ging
, 21(
1), 1
90-1
95.
Pres
ente
d at
the
45th
Ann
ual S
cien
tific
& E
duca
tiona
l Mee
ting
of th
e C
anad
ian
Ass
ocia
tion
on G
eron
tolo
gy
Fund
ing
prov
ided
by:
22
Rur
al/R
emot
e an
d In
dige
nous
old
er a
dults
are
vul
nera
ble
due
to
rest
ricte
d ac
cess
to lo
cal s
uppo
rts &
ser
vice
s an
d ar
e, th
eref
ore,
the
quin
tess
entia
l end
-use
rs fo
r AG
E-W
ELL
tech
nolo
gies
Unm
et N
eeds
of R
ural
/Rem
ote
Old
er A
dults
: Opp
ortu
nitie
s fo
r Tec
hnol
ogy
Dev
elop
men
tO
’Con
nell,
M. E
.1 ,G
ould
, B.1 ,
Sce
rbe,
A.1 ,
Mor
gan,
D.1 ,
, C
arte
r, J.
1 , Bo
uras
sa, C
.2,3 ,
Ow
l, N
.2 , J
ackl
in, K
.4 , W
arry
, W.5
AG
E-W
ELL
HQ
P
Und
erst
andi
ngus
erne
eds
isfu
ndam
enta
lto
the
deve
lopm
ento
fuse
fult
echn
olog
y.Th
eus
erne
eds
oftw
oun
ique
popu
latio
nsar
eex
plor
edin
AGE-
WEL
L’s
RR
ITE:
Rur
al/R
emot
eIn
dige
nous
Tech
nolo
gyne
eds
Expl
orat
ion.
Thes
eol
der
adul
tsar
evu
lner
able
due
tore
stric
ted
acce
ssto
loca
lsup
ports
and
serv
ices
(Ste
el&
Lo,
2013
;M
aar,
Seym
our,
Sand
erso
n&
Boes
ch,2
010)
.Fo
rth
ecu
rrent
stud
y,ge
nera
lun
met
need
sre
porte
dby
rura
l/rem
ote
dwel
ling
olde
rad
ults
wer
eex
plor
edby
brie
fint
ervi
ew.
Mos
t (30
7) d
escr
ibed
nee
ded
phys
ical
ass
ista
nce
due
to
stre
ngth
lim
itatio
ns o
r var
ious
m
edic
al c
ondi
tions
66 d
escr
ibed
nee
ding
hel
p us
ing
tech
nolo
gy (s
uch
as tu
rnin
g on
a
com
pute
r, or
bur
ning
a C
D)
few
er m
entio
ned
othe
r di
fficu
lties
, e.g
., •
12 m
entio
ned
limita
tions
due
to
inab
ility
to d
rive,
•
7 m
entio
ned
limita
tions
re
late
d to
men
tal h
ealth
co
nditi
ons
Parti
cipa
nts
wer
ere
crui
ted
from
rand
omly
sele
cted
tele
phon
enu
mbe
rs(la
ndlin
esan
dce
llph
ones
)lis
ted
for
pers
ons
resi
ding
outs
ide
met
ropo
litan
area
sof
Sask
atch
ewan
,an
dw
aspr
edom
inan
tlyru
ral/r
emot
e(a
lthou
gh10
inth
esa
mpl
ew
ere
from
asm
allc
ityof
10,5
00,
mos
tw
ere
from
smal
ler
cent
ers,
larg
est,
5,50
0).
621
rura
l/rem
ote
seni
ors
wer
ere
crui
ted
(Mag
e=
71.5
;SD
=8.
4;ra
nge
60-1
02ye
ars)
Of
this
sam
ple,
502
seni
ors
resp
onde
dto
anop
en-e
nded
ques
tion
rega
rdin
ga
time
whe
nth
eyne
eded
assi
stan
ce,
and
data
wer
eth
emat
ical
lyan
alyz
ed(w
ithN
VIVO
fors
uppo
rt).
Thes
eda
tasu
gges
ttec
hnol
ogy
deve
lope
dto
augm
entp
hysi
calt
asks
will
becr
itica
lfor
rura
l/rem
ote
seni
ors,
buta
lso
high
light
sth
ene
edfo
rint
uitiv
ean
dus
eabl
ete
chno
logi
es.
RR
ITE’
s w
ork
will
info
rm d
evel
opm
ent a
nd a
dapt
atio
n of
tech
nolo
gy to
incr
ease
acc
essi
bilit
y fo
r ol
der C
anad
ians
who
are
of I
ndig
enou
s an
cest
ry a
nd/o
r who
resi
de in
rura
l or r
emot
e lo
catio
ns.
1 5
2
3
4
Maa
r, M
. A.,
Seym
our,
A., S
ande
rson
, B.,
& Bo
esch
, L. (
2010
). R
each
ing
agre
emen
t for
an
Abor
igin
al e
-hea
lth re
sear
ch a
gend
a:
The
Abor
igin
al T
eleh
ealth
kno
wle
dge
circ
le c
onse
nsus
met
hod.
Rur
al a
nd R
emot
e H
ealth
, 10,
129
9-13
12.
Stee
le, R
. & L
o, A
. (20
13).
Tele
heal
th a
nd u
biqu
itous
com
putin
g fo
r ban
dwith
-con
stra
ined
rura
l and
rem
ote
area
s. P
erso
nal a
nd
Ubi
quito
us C
ompu
ting,
17(
3), 5
33-4
3.
23
Are
all b-
amyl
oid
pept
ides
bad
?*A
pre
limin
ary
inve
stig
atio
n*
Maa
O. Q
uart
ey1 ;
Jenn
ifer
N.K
. Nya
rko1 ;
Pau
l R. P
enni
ngto
n1 ; B
radl
ey M
. Cha
hary
n1 ,Ja
son
Mal
ey2 ,
Gle
nB
.Bak
er3 ;
Dar
rell
D. M
ouss
eau1
1: C
ell S
igna
lling
Lab
orat
ory,
Dep
artm
ent o
f Psy
chia
try,
Uni
vers
ity o
f Sas
katc
hew
an; 2
: Sas
katc
hew
an S
truc
tura
l Sci
ence
s Cen
ter,
Uni
vers
ity o
f Sas
katc
hew
an; 3
: Neu
roch
emic
al R
esea
rch
Uni
t, D
epar
tmen
t of P
sych
iatr
y, U
nive
rsity
of A
lber
ta
Intr
oduc
tion/
Obj
ectiv
e:St
udie
sof
Alz
heim
erdi
seas
e(A
D)
brai
nis
olat
esha
vere
veal
edth
atth
eph
ysio
logi
cal
Ab(
1-40
)fr
agm
ent
and
the
mor
ehy
drop
hobi
c–a
ndA
D-r
elev
ant–
Ab(
1-42
)sp
ecie
sac
coun
tsfo
rm
ost
ofth
ede
tect
able
Ab.
Ther
eis
exte
nsiv
eC
-term
inal
and
N-te
rmin
alhe
tero
gene
ityof
extra
ctab
leAb
pept
ides
,al
thou
ghth
eir
role
(s)
inA
D-r
elat
edpa
thol
ogy
rem
ain
uncl
ear,
likel
ybe
caus
eof
scre
ens
forp
opul
atio
ntre
nds
rath
erth
anfo
rind
ivid
ualp
atte
rns.
We
chos
eto
exam
ine
how
the
patte
rnof
Ab
spec
ies
com
pare
din
solu
ble
and
inso
lubl
efr
actio
nsfr
omth
esa
me
sour
ce.
Des
ign
and
Met
hods
:Hip
poca
mpa
lsam
ples
obta
ined
from
cont
rola
ndA
Ddo
nors
asw
ell
asfr
omth
e‘J
20’
mou
sest
rain
that
harb
ors
ahu
man
doub
le-s
ubst
itute
dSw
edis
h/In
dian
aA
PPtra
nsge
new
ere
used
tode
term
ineAβ
frag
men
tatio
npa
ttern
sin
solu
ble
and
inso
lubl
efr
actio
ns.T
his
was
done
usin
gse
quen
tial
imm
unop
reci
pita
tion
stra
tegi
esan
dvi
sual
ized
usin
gW
este
rnbl
ottin
gte
chni
ques
.W
eus
eda
cell-
free
Thio
flavi
n-T
(ThT
)flu
ores
cenc
eas
say,
circ
ular
dich
rois
m,
and
surf
ace
plas
mon
reso
nanc
eto
dete
rmin
eth
ein
fluen
ceof
the
Ab(
1-38
)pe
ptid
eson
the
fibril
lar
beha
viou
rofl
onge
r,A
D-r
elev
antA
βsp
ecie
s.R
esul
ts:I
nth
eJ2
0m
ice,
we
obse
rved
that
high
erle
vels
ofa
smal
lerA
βsp
ecie
s,w
hich
alig
nsw
ithsy
nthe
ticAβ(
1-38
)in
the
solu
ble
frac
tion
inva
riabl
yal
igne
dw
ithlit
tleor
noAβ(
1-40
/42)
inth
eco
rres
pond
ing
inso
lubl
efr
actio
n.In
the
auto
psie
dsa
mpl
es,
asi
mila
rpa
ttern
was
reve
aled
;i.e
.in
AD
sam
ples
with
less
Ab(
1-42
)in
the
inso
lubl
efr
actio
n,th
ere
was
mor
eof
the
smal
ler,
solu
ble
Ab
spec
ies
(36?
37?
38?)
.Thi
spa
ttern
was
mor
eev
iden
tin
the
corti
cals
ampl
esof
fem
aleA
Ddo
nors
.Sy
nthe
ticAb(
1-38
),Ab(
1-42
)an
dAb(
1-43
)pe
ptid
esun
derw
enta
conv
ersi
onto
b-sh
eets
truct
ure,
asex
pect
ed,b
utth
era
teof
b-sh
eetc
onve
rsio
n/Th
Tbi
ndin
gof
the
42-
and
43-m
ers
was
sign
ifica
ntly
redu
ced
whe
nth
ese
wer
eco
-incu
bate
dfo
rlo
nger
incu
batio
ntim
esw
ith10
0xlo
wer
mol
arco
ncen
tratio
nsof
Ab(
1-38
).C
ell
mor
talit
yas
soci
ated
with
the
long
er,n
euro
toxi
cfr
agm
ents
was
reve
rsed
byAb(
1-38
).C
oncl
usio
ns:O
urda
tasu
gges
ttha
tAb(
1-38
)mig
htbe
ana
tura
linh
ibito
rofA
b(1-
40+)
fibril
loge
nesi
san
dco
uld
have
sign
ifica
ntre
leva
nce
tore
gula
ting
the
onse
tof
neur
otox
icity
asso
ciat
edw
ithth
ese
long
er,
mor
ehy
drop
hobi
cAb
spec
ies
inm
ouse
mod
elso
fAD
asw
ella
sin
the
clin
ical
cont
ext.
Fig.
1: C
leav
age
of A
PP b
y se
cret
ases
yie
lds A
bfr
agm
ents
of
vary
ing
leng
ths.
The
Am
yloi
dPr
otei
nPr
ecur
sor
(APP
)ca
nbe
sequ
entia
llycl
eave
dby
vario
usse
cret
ases
toyi
eldb-
amyl
oid
frag
men
ts(Ab:
high
light
edas
the
red
rect
angl
e)of
vary
ing
leng
ths.
Res
earc
hfo
cuse
son
the
phys
iolo
gica
lAb(
1-40
)an
dth
ehy
drop
hobi
c(a
ndpa
thol
ogic
)Ab(
1-42
)th
atte
nds
tole
adto
aggr
egat
eskn
own
asam
yloi
dpl
aque
s(ri
ght).
How
ever
,the
AD
brai
nco
ntai
nsfa
rm
ore
than
thes
efr
agm
ents
,w
ithth
eas
sum
ptio
nth
atal
lAb
frag
men
tsar
eto
xic.
plaq
ues
Ack
now
ledg
men
ts:D
DM
isth
eSa
skat
chew
anR
esea
rch
Cha
irin
Alzh
eim
erdi
seas
ean
dre
late
dde
men
tiath
atis
join
tlyfu
nded
byth
eA
lzhe
imer
Soci
ety
ofSa
skat
chew
anan
dth
eSa
skat
chew
anH
ealth
Res
earc
hFo
unda
tion.
Fig.
2:T
hede
tect
ion
ofth
eAb(
1-38
)in
the
solu
ble
frac
tion
alig
nsw
ithle
ss40
/42-
mer
sin
the
inso
lubl
efr
actio
n.
Solu
ble
(RIP
A)a
ndin
solu
ble
(gua
nidi
um)f
ract
ions
ofm
ouse
corti
cal(
top
pane
l)an
dhu
man
hipp
ocam
pal(
botto
mpa
nel)
sam
ples
wer
eim
mun
opre
cipi
tate
dfo
r6E1
0(a
nti-
Ab(
1-17
)an
tibod
y)an
dre
solv
edon
8MU
rea
gels
.The
reso
lved
Ab
frag
men
tsw
ere
com
pare
dto
synt
hetic
pept
ides
(not
show
n).
Fig.
3:Ab(
1-38
)alte
rsth
eT
hTbi
ndin
gof
the
42-/4
3-m
er.
Gen
eral
cons
ider
atio
ns:
•Th
Tan
dC
Dan
dSP
Rsu
gges
ttha
tin
the
shor
t-ter
m,A
bpe
ptid
esac
tsim
ilarly
,but
whe
nco
-incu
bate
dfo
rlon
gerp
erio
dsof
time,
the
Ab(
1-38
)pep
tide
tend
sto
miti
gate
the
effe
cts
ofth
elo
nger
,mor
ehy
drop
hobi
can
dne
urot
oxic
Ab
pept
ides
.•
Cou
ldth
isex
plai
nth
ein
vers
ere
latio
nbe
twee
nAb(
1-38
)in
solu
ble
frac
tions
and
Ab(
1-40
)orA
b(1-
42)i
nin
solu
ble
frac
tions
ofA
PPm
ouse
.and
hum
anA
Dsa
mpl
es?
(top
pane
l)C
ircul
ardi
chro
ism
(CD
)was
used
toes
timat
epr
otei
nse
cond
ary
stru
ctur
e,i.e
.a-h
elix
,b-s
heet
,b-tu
rnan
dra
ndom
coil
inpr
epar
atio
nsof
Ab(
1-38
),Ab(
1-42
)and
Ab(
1-43
),ei
ther
alon
eor
inco
mbi
natio
n.(b
otto
m,l
eftp
anel
)are
pres
enta
tive
spec
trum
ofth
ein
divi
dual
Ab
frag
men
ts.
(bot
tom
,ri
ght
pane
l)Su
rfac
epl
asm
onre
sona
nce
(SPR
)de
mon
stra
tes
that
,at
two
hour
sof
co-in
cuba
tion,
Ab(
1-38
)do
esno
tsi
gnifi
cant
lyal
ter
the
bind
ing
ofAb(
1-42
)to
itsel
f.Th
isre
flect
sth
ela
ckof
effe
ctof
Ab(
1-38
)on
the
CD
prof
ileof
Ab(
1-42
)at
the
sam
etim
e-po
int.
We
are
curr
ently
exam
inin
glo
nger
incu
batio
ntim
e-po
ints
.
Fig.
4:Se
cond
ary
stru
ctur
esof
Ab(
1-42
)an
dAb(
1-43
)ar
eal
tere
dby
long
-ter
mco
-incu
batio
nw
ithAb(
1-38
).
Fig.
5:Ab(
1-38
)re
vers
esth
eto
xici
tyof
the
42-/4
3-m
ers.
Mou
sehi
ppoc
ampa
lH
T-22
cells
wer
etre
ated
(24
h)w
ith5mM
ofpe
ptid
esin
divi
dual
lyor
inco
mbi
natio
n,as
indi
cate
d,an
dth
enm
onito
red
for
viab
ility
.*:
P<0.
05vs
Ab(
1-38
).
24
Ger
iatr
ic A
sses
smen
t Ser
vice
(P
ropo
sal)
Wen
dy Q
uinn
RN
(NP
), M
S., N
P-C
Yog
endr
eeH
amm
ond
Pha
rmaD
; MB
A; B
Pha
rm; C
DE
Dr.
Ear
le D
eCot
eau
MD
FR
CP
(c);E
mer
itus
Pro
fess
or, U
of S
Col
lege
of M
edic
ine
Pro
gram
P
roce
ss
NP
Ini
tial
Con
tact
( P
hone
)
Hom
e V
isit
by N
P –
Com
preh
ensi
ve
Ger
iatr
ic A
sses
smen
t
Pha
rma
D -
Med
icat
ion
The
rapy
Ger
iatr
ic
S pec
ialis
t A
sses
smen
t
Par
tner
ship
s:•
PA
PH
R•
SK H
ealth
•G
EM
•P
T, O
T S
ervi
ces
•H
ome
Car
e•
Acu
te C
are
•P
rim
ary
Car
e•
CA
DT
H
Intr
oduc
tion
The
re is
a g
row
ing
need
of
serv
ices
for
the
agin
g p o
pula
tion.
Sas
katc
hew
an
Hea
lth is
cur
rent
ly a
ddre
ssin
g t h
e tr
end
of fr
ail e
lder
ly
freq
uent
ly v
isiti
ng E
mer
genc
y D
epar
tmen
ts (E
D),
and
incr
ease
d ho
spita
l adm
issi
ons
a nd
stay
s. T
here
are
cur
rent
ly
no s
peci
fic c
ompr
ehen
sive
ge
riat
ric
serv
ices
in th
e P
rinc
e A
lber
t are
a th
at a
ddre
ss th
is
n eed
in th
e co
mm
unity
bef
ore
they
bec
ome
an a
cute
ED
vis
it.
Pro
gram
Goa
ls•
Iden
tify
the
popu
latio
n of
el
derl
y in
nee
d of
c o
mpr
ehen
sive
/pre
vent
ativ
e se
rvic
e•
Opt
imiz
e ex
istin
g re
sour
ces
in
t he
com
mun
ity to
add
ress
ne
eds
•Fo
cus
on G
eria
tric
Gia
nts
in
guid
ing
heal
th m
anag
emen
t•
Max
imiz
e pa
tient
func
tion
and
i nde
pend
ence
as
long
as
poss
ible
•P
rovi
de s
uppo
rt/e
duca
tion
to
care
give
rs•
Red
uce
risk
of h
ospi
taliz
atio
n
Com
preh
ensi
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26
Clu
ster
Ran
dom
ized
Cont
rolle
d Tr
ial o
f the
Dec
isio
n To
ol
Pa
rtic
ipan
ts w
ere
stra
tifie
d by
gen
der a
nd ra
ndom
ized
A pa
ralle
l-gro
up ra
ndom
ized
cont
rolle
d tr
ial w
as c
ondu
cted
to a
sses
s the
impa
ct o
f th
e on
line
deci
sion
tool
- i
n th
e ex
perim
enta
l ver
sion
of th
e to
ol, p
artic
ipan
ts re
ceiv
ed a
n al
gorit
hm-b
ased
re
com
men
datio
n on
whe
ther
or n
ot to
repo
rt th
eir p
atie
nt to
lice
nsin
g au
thor
ities
,
an e
duca
tiona
l pac
kage
for f
amili
es a
nd sp
ecia
lized
repo
rtin
g fo
rms
- i
n th
e co
ntro
l ver
sion
of th
e to
ol, p
artic
ipan
ts re
ceiv
ed o
nly
a ge
neric
rem
inde
r
abo
ut re
port
ing
legi
slatio
n
Qua
ntita
tive
anal
ysis
exa
min
ed p
artic
ipan
ts’ r
epor
ting
deci
sions
rela
tive
to “
per-
prot
ocol
” de
cisio
n (a
s det
erm
ined
by
the
DADI
O st
udy
algo
rithm
), as
wel
l as w
heth
er
or n
ot th
ey re
com
men
ded
a sp
ecia
lized
on-
road
driv
ing
test
for t
heir
patie
nt
Qua
litat
ive
anal
ysis
of p
ost-
RCT
inte
rvie
ws e
xam
ined
par
ticip
ants
’ exp
erie
nces
usin
g th
e de
cisio
n to
ol, t
he im
pact
of t
he to
ol o
n w
orkf
low
and
the
doct
or-p
atie
nt
rela
tions
hip
Sam
ple
size
cal
cula
tion
was
bas
ed o
n an
exp
ecte
d ba
se re
port
ing
rate
of 1
3% in
fam
ily
phys
icia
ns, a
nd a
n es
timat
ed 1
0% d
iffer
ence
bet
wee
n co
ntro
l and
inte
rven
tion
grou
ps
(i.
e. th
e to
ol w
ould
incr
ease
per
-pro
toco
l rep
orts
from
13%
to 2
3%)
Mar
k J R
apop
ort1 ,
Carla
Zuc
cher
o Sa
rrac
ini1 ,
Lind
a Ro
zmov
its2 ,
Alex
Kiss
3 , In
na G
rigor
iev4 ,
Rebe
cca
Tayl
or5 ,
Nat
han
Herr
man
n1 , Be
noit
H M
ulsa
nt6 ,
Dunc
an C
amer
on7 ,
Chris
toph
er F
rank
8 , Da
llas S
eitz
9 , An
na B
ysze
wsk
i10, D
avid
Tang
-Wai
11, M
ario
Mas
ellis
1 , Fr
ank
Mol
nar10
and
Gar
y N
aglie
12
Estim
ates
of 1
.1 m
illio
n ol
der a
dults
with
dem
entia
in C
anad
a by
203
8
Cras
h ra
tes i
n de
men
tia a
re in
crea
sed
2-8
times
rela
tive
to a
ge-m
atch
ed c
ontr
ols,
but
be
twee
n 22
% a
nd 6
4% o
f pat
ient
s with
dem
entia
con
tinue
to d
rive
Ph
ysic
ian
com
plia
nce
with
man
dato
ry re
port
ing
legi
slatio
n is
low
Our
rece
nt D
rivin
g an
d De
men
tia in
Ont
ario
(DAD
IO) s
tudy
use
d a
mod
ified
Del
phi p
roce
ss
to o
btai
n ex
pert
con
sens
us o
n w
hich
pat
ient
s with
mild
dem
entia
or m
ild c
ogni
tive
impa
irmen
t (M
CI) s
houl
d be
repo
rted
to tr
ansp
orta
tion
auth
oriti
es
De
men
tia e
xper
ts re
view
ed 2
6 hy
poth
etic
al ca
se sc
enar
ios o
ver 5
iter
atio
ns
and
cam
e to
con
sens
us (d
efin
ed a
s >85
% a
gree
men
t) o
n 69
% o
f the
cas
es
Th
e re
sults
of t
he D
ADIO
stud
y w
ere
adap
ted
into
an
algo
rithm
to h
elp
phys
icia
ns d
ecid
e w
hich
pat
ient
s with
MCI
or m
ild d
emen
tia sh
ould
be
repo
rted
P
ROJE
CT G
OAL
Th
e go
al o
f the
pre
sent
stud
y is
to u
se a
mul
ti-fa
cete
d kn
owle
dge
tr
ansl
atio
n in
terv
entio
n to
aid
phy
sici
ans i
n de
cidi
ng w
hen
to re
port
old
er
driv
ers w
ith m
ild d
emen
tia o
r MCI
to tr
ansp
orta
tion
auth
oriti
es.
D
evel
opm
ent o
f the
Dec
isio
n To
ol
A
varie
ty o
f app
roac
hes w
ere
used
to d
evel
op th
e Dr
ivin
g in
Dem
entia
Dec
ision
Tool
:
a sy
stem
atic
lite
ratu
re a
nd g
uide
line
revi
ew
De
lphi
exp
ert o
pini
on fr
om th
e DA
DIO
stud
y
Inte
rvie
ws a
nd fo
cus g
roup
s with
phy
sicia
ns, f
amily
car
egiv
ers o
f per
sons
w
ith d
emen
tia a
nd tr
ansp
orta
tion
adm
inist
rato
rs
A
com
pute
rized
dec
isio
n su
ppor
t too
l was
dev
elop
ed
Th
e to
ol p
rodu
ces a
reco
mm
enda
tion
for r
epor
ting
patie
nts w
ith m
ild
dem
entia
or M
CI to
tran
spor
tatio
n au
thor
ities
.
Re
com
men
datio
ns a
re:
“
Repo
rt”
“D
o N
ot R
epor
t”
“N
o Co
nsen
sus”
Th
e to
ol in
clud
es a
n ed
ucat
iona
l res
ourc
e pa
ckag
e fo
r the
per
son
with
dem
entia
or M
CI
an
d hi
s/he
r car
egiv
er, a
s wel
l as c
usto
mize
d re
port
ing
form
s for
the
phys
icia
n to
use
M
ain
Find
ings
The
Driv
ing
in D
emen
tia D
ecisi
on To
ol is
eas
y to
lear
n an
d ea
sy to
use
Ho
wev
er, a
lmos
t 50%
of p
artic
ipan
ts d
id n
ot u
se th
e to
ol a
t all
Re
sults
are
bas
ed o
n a
limite
d nu
mbe
r of u
ses o
f the
tool
Som
e pa
rtic
ipan
ts fo
und
it ch
alle
ngin
g to
rem
embe
r to
use
the
tool
and
inte
grat
e it
into
da
ily w
orkf
low
Th
e to
ol d
id n
ot in
crea
se p
hysic
ian
repo
rtin
g of
pat
ient
s with
mild
dem
entia
or M
CI to
tr
ansp
orta
tion
auth
oriti
es, b
eyon
d th
e ef
fect
s of c
areg
iver
con
cern
and
clo
ck d
raw
ing
abno
rmal
ities
The
tool
may
be
mor
e us
eful
for g
ener
alist
s tha
n sp
ecia
lists
Th
e to
ol m
ay h
ave
unex
pect
ed v
alue
as a
teac
hing
tool
Fu
ture
Dire
ctio
ns
Ad
dres
s the
cha
lleng
e of
enc
oura
ging
tool
use
and
inte
grat
ing
the
tool
into
day
-to-d
ay
wor
kflo
w
Cons
ider
way
s to
enga
ge fa
mily
phy
sicia
ns, w
ho m
ay b
enef
it m
ost f
rom
the
Deci
sion
Tool
Ex
tend
the
tool
to o
ther
clin
icia
ns
Cont
inue
inve
stig
atin
g th
e im
port
ant r
ole
of c
areg
iver
con
cern
in d
ecisi
ons r
elat
ing
to
driv
ing
safe
ty in
indi
vidu
als w
ith m
ild d
emen
tia a
nd M
CI
(1)
Sunn
ybro
ok H
ealth
Scie
nces
Cen
tre,
Toro
nto,
ON,
Can
ada,
(2) I
ndep
ende
nt p
ract
ice, T
oron
to, O
N, C
anad
a, (3
) Sun
nybr
ook
Rese
arch
Inst
itute
, Tor
onto
, ON,
Can
ada,
(4) Y
ork
Univ
ersit
y (S
tude
nt),
Toro
nto,
ON,
Can
ada,
(5) B
aycr
est,
Toro
nto,
ON
, Can
ada,
(6) C
entr
e fo
r Add
ictio
n an
d M
enta
l Hea
lth, T
oron
to, O
N, C
anad
a,
(7) M
cMas
ter U
nive
rsity
(stu
dent
), Ha
milt
on, O
N, C
anad
a, (8
) Pro
vide
nce
Care
, Kin
gsto
n, O
N, C
anad
a, (9
) Que
en's
Univ
ersit
y, Ki
ngst
on, O
N, C
anad
a, (1
0) T
he O
ttaw
a Ho
spita
l, O
ttaw
a, O
N, C
anad
a, (1
1) U
nive
rsity
Hea
lth N
etw
ork,
Tor
onto
, ON
, Can
ada,
(12)
Bay
cres
t Hea
lth S
cienc
es, T
oron
to, O
N, C
anad
a
DISC
USS
ION
Hom
epag
e fo
r the
Driv
ing
in D
emen
tia D
ecisi
on To
ol
MET
HODS
- PA
RT II
MET
HODS
- PA
RT I
Patie
nt d
ata
requ
ired
to u
se th
e Dr
ivin
g in
De
men
tia D
ecisi
on To
ol
ACKN
OW
LEDG
EMEN
TS
Fund
ing
for t
his w
ork
was
pro
vide
d by
the
Cana
dian
Inst
itute
s of
Hea
lth R
esea
rch
(CIH
R Kn
owle
dge
Synt
hesis
Gra
nt
#KAL
1298
96, J
une
1, 2
013
to M
ay 3
0, 2
015)
.
Q
uant
itativ
e Re
sults
as o
f Oct
ober
201
5
68 p
artic
ipan
ts w
ere
rand
omize
d:
Inte
rven
tion
grou
p:
Cont
rol g
roup
:
-
35 p
artic
ipan
ts ra
ndom
ized
-
33
part
icip
ants
rand
omize
d
- 20
/35
used
the
tool
(57%
use
rs)
- 1
6/33
use
d th
e to
ol (4
9% u
sers
)
- 10
0 va
lid u
ses
- 86
val
id u
ses
T
he p
ropo
rtio
n of
pat
ient
s rep
orte
d to
lice
nsin
g au
thor
ities
per
-pro
toco
l did
not
diff
er
stat
istic
ally
bet
wee
n th
e in
terv
entio
n an
d co
ntro
l gro
ups (
49%
vs.
43%
; Z=-
1.02
, p=0
.31)
The
act
ual b
ase
repo
rtin
g ra
te w
as m
uch
high
er th
an a
ntic
ipat
ed (4
3% in
stea
d of
13%
)
and
the
diffe
renc
e be
twee
n gr
oups
was
smal
ler t
han
expe
cted
(6%
inst
ead
of 1
0%)
In m
ultiv
aria
te a
naly
sis, c
areg
iver
con
cern
(OR
6.2,
95%
CI 2
.7-1
4.3,
p<0
.000
1) a
nd
abno
rmal
cloc
k dr
awin
g (O
R 10
.6, 9
5% C
I 5.0
-22.
5, p
<0.0
001)
pre
dict
ed p
er-p
roto
col
repo
rtin
g
Fem
ale
phys
icia
ns w
ere
mor
e lik
ely
than
mal
es to
reco
mm
end
a fo
rmal
road
test
for t
heir
patie
nts w
ith m
ild d
emen
tia o
r MCI
(OR
3.4,
95%
CI 1
.1-1
0.1,
p=0
.03)
, but
no
gend
er
diffe
renc
es w
ere
foun
d in
repo
rtin
g
Qua
litat
ive
Resu
lts
So
me
frus
trat
ion
with
the
“No
Cons
ensu
s” re
com
men
datio
ns fo
r int
erve
ntio
n gr
oup
user
s
M
ost p
artic
ipan
ts sa
id th
e to
ol w
as e
asy
to u
se
Som
e pa
rtic
ipan
ts fo
und
the
tool
diff
icul
t to
inte
grat
e in
to th
eir d
ay-to
-day
wor
kflo
w
Som
e pa
rtic
ipan
ts fe
lt th
e to
ol w
ould
be
mor
e va
luab
le fo
r fam
ily p
hysic
ians
than
for
spec
ialis
ts
Part
icip
ants
foun
d va
riabl
e w
ays o
f usin
g th
e to
ol, e
.g. s
ome
used
it o
nly
in “g
ray
area
” ca
ses
504
186
68
0
100
200
300
400
500
600
Tool
Use
sPa
rtic
ipan
ts
Expe
cted
Actu
al
56
024681012141618
01
23
45
67
89
1011
1213
NUMBER OF PARTICIPANTS
NU
MBE
R O
F U
SES In
terv
entio
n
Cont
rol
Driv
ing
in D
emen
tia D
ecis
ion
Tool
(DD
-DT)
In
terv
entio
n Co
mpu
teriz
ed C
linic
al
Deci
sion
Supp
ort S
yste
m
(CCD
SS)
Ed
ucat
iona
l Pac
kage
Spec
ializ
ed R
epor
ting
Form
Expe
cted
vs.
Actu
al p
artic
ipan
ts a
nd u
ses
Num
ber o
f Use
s by
Grou
p
PREL
IMIN
ARY
RESU
LTS
INTR
ODU
CTIO
N
27
•Sa
skat
chew
an=
larg
e se
nior
pop
ulat
ion
that
is ri
sing
.
•R
ural
are
a he
alth
pro
fess
iona
ls s
trugg
le w
ith a
dded
pr
essu
res
ass
ocia
ted
with
pra
ctic
e in
rura
l are
as.
•N
eed
for a
pro
cess
that
wou
ld e
ase
diag
nost
ic
unce
rtain
ty a
nd e
nhan
ce ti
mel
y di
agno
sis.
•N
eed
to re
sear
ch e
xist
ing
mod
es o
f con
tinue
d ed
ucat
ion
to d
eter
min
e th
e be
st m
ode
of d
eliv
ery
on
train
ing,
dia
gnos
is, a
nd m
anag
emen
t.
•Pr
esen
t res
earc
h en
tails
wor
k w
ith ru
ral P
rimar
y H
ealth
Car
e Te
ams
(PH
C te
ams)
loca
ted
in S
un
Cou
ntry
Hea
lth R
egio
n. W
e pl
an to
util
ize
parti
cipa
tory
act
ion
rese
arch
to e
nhan
ce te
am
parti
cipa
tion.
INT
RO
DU
CT
ION
•Ti
mel
y de
men
tia d
iagn
osis
→cr
ucia
l for
tre
atm
ent a
nd c
are
man
agem
ent1 .
•Sy
mpt
oms→
diffi
cult
to d
etec
t2 .
•Pr
imar
y ca
re p
rovi
ders
→in
regu
lar c
onta
ct w
ith in
divi
dual
s w
ithde
men
tia3 .
Bar
riers
to d
iagn
osis
4 :•
Neg
ativ
e at
titud
es to
war
d sp
ecia
list r
efer
rals
.•
Perc
eive
d lim
ited
treat
men
t opt
ions
.•
Neg
ativ
e an
ticip
ated
out
com
es fr
om
disc
losu
re.
•Pe
rcep
tion
of d
emen
tia a
s ac
cept
ed p
art o
f gr
owin
g ol
der.
Uni
que
chal
leng
es in
rura
l are
as5,
6 :•
Wor
k is
olat
ion.
•
Less
acc
ess
to s
peci
alis
ts.
•In
adeq
uate
ly s
taffe
d pr
ogra
ms.
•Lo
ng w
ait t
imes
for s
ervi
ces.
•Lo
nger
dis
tanc
es to
spe
cial
ized
pro
gram
s.•
Few
er e
duca
tiona
l res
ourc
es.
•Va
ried
leve
ls o
f dem
entia
edu
catio
n by
pr
ofes
sion
, and
role
.
•Va
ried
pref
erre
d m
odes
of d
eliv
ery
of re
mot
e ed
ucat
ion.
Ass
essm
ent o
f Prim
ary
Hea
lth C
are
Lear
ning
Nee
ds in
a R
ural
Are
a OB
JEC
TIV
ES
A. S
cerb
e1, M
. E. O
’Con
nell1
1 D
epar
tmen
t of P
sych
olog
y, U
nive
rsity
of S
aska
tche
wan
PR
OJE
CT
S
1In
nes,
A.,
Szym
czyn
ska,
P.,
& St
ark,
C. (
2015
). D
emen
tia d
iagn
osis
and
pos
t-dia
gnos
tic s
uppo
rt in
Sco
ttish
rura
l com
mun
ities
: ex
perie
nces
of p
eopl
e w
ith d
emen
tia a
nd th
eir f
amilie
s. D
emen
tia, 1
3(2)
,233
-247
. doi
: 10.
117
7/14
7130
1212
4606
082
Gre
enw
ay-C
rom
bie,
A.,
Snow
, P.,
Dis
ler,
P., D
avis
, S.,
& Po
nd, D
. (20
12).
Influ
ence
of r
ural
ity o
n di
agno
sis
dem
entia
in A
ustra
lian
prac
tice.
Aus
tralia
n Jo
urna
l of P
rimar
yH
ealth
, 18(
3),1
78-1
84.
3M
itche
ll, A
. J.,
Mea
der,
& Pe
ntze
k, M
. (20
11).
Clin
ical
reco
gniti
on o
f dem
entia
and
cog
nitiv
e im
pairm
ent i
n pr
imar
y ca
re: a
met
a-an
alys
is o
f phy
sici
an a
ccur
acy.
Act
aP
sych
iatri
caS
cand
inav
ica,
124
,165
-183
. Doi
: 10.
111
1/j.
1600
-044
7. 2
011.
017
30. x
4C
ody,
M.,
Beck
, C.,
Shue
, V. M
., &
Pope
, S. (
2002
). R
epor
ted
prac
tices
of p
rimar
y ca
re p
hysi
cian
s in
the
diag
nosi
s an
d m
anag
emen
t of
dem
entia
, Agi
ng a
nd M
enta
l Hea
lth, 6
(1),
72-7
6. d
oi: 1
0. 1
080/
1360
7860
1201
0115
8 5
Kost
eniu
k, J
., M
orga
n, D
., In
nes,
A.,
Kead
y, J.
, Ste
war
t, N
., D
’Arc
y, C
., Ki
rk, A
. (20
13).
Who
ste
ers
the
ship
? R
ural
fam
ily p
hysi
cian
s vi
ews
in c
olla
bora
tive
care
mod
els
for p
atie
nts
with
dem
entia
. Prim
ary
Hea
lth C
are
Res
earc
h &
Dev
elop
men
t, 15
, 104
-110
. do
i:10.
1017
/S14
6342
3613
0001
1X6
Mor
gan,
D.,
Inne
s, A
., &
Kost
eniu
k, J
. (20
11).
Dem
entia
car
e in
rura
l and
rem
ote
setti
ngs:
asy
stem
atic
revi
ew o
f for
mal
or p
aid
care
. M
atur
itas,
68,
17-3
3. d
oi: 1
0. 1
016/
j. m
atur
itas.
201
0. 0
9. 0
08
ST
UD
Y R
AT
ION
ALE
RR
MC
Fun
ding
and
in-k
ind
supp
ort i
s ge
nero
usly
pro
vide
d by
:
•(1
) Exa
min
e ex
istin
g ed
ucat
iona
l pro
gram
s to
un
ders
tand
wha
t has
bee
n do
ne u
p to
dat
e.
•(2
) Eva
luat
e ed
ucat
iona
l nee
ds o
f PH
C m
embe
rs a
nd
thei
r pre
fere
nces
for e
duca
tion
deliv
ery
as w
ell a
s ba
rrier
s to
bes
t pra
ctic
e.
•(4
) Del
iver
y of
pro
gram
ass
ocia
ted
mat
eria
ls v
ia
smar
t pho
ne a
pplic
atio
n.
Proj
ect 1
•Sc
opin
g re
view
of e
xist
ing
mod
es o
f del
iver
y fo
r re
mot
e co
ntin
ued
educ
atio
n.•
Will
serv
e to
info
rm fu
ture
wor
k.•
Qua
litat
ive
data
ana
lysi
s.
Proj
ect 2
•Ex
plor
atio
n of
pre
ferre
d m
odes
of e
duca
tiona
l de
liver
y, p
erce
ived
bar
riers
, and
sea
rch
for t
he m
ost
effe
ctiv
e m
etho
d of
impl
emen
tatio
n.
•In
terv
iew
s w
ith P
HC
mem
bers
.•
Qua
litat
ive
anal
ysis
.
Proj
ect 3
•D
eliv
ery
of p
rogr
am m
ater
ials
via
mob
ile a
pplic
atio
n (iE
pi).
•Im
plem
enta
tion
of S
pace
d Ed
ucat
ion
deliv
ery
to
enha
nce
know
ledg
e re
tent
ion.
•Im
plem
enta
tion
will
be d
eter
min
ed b
y th
e PH
C te
ams.
28
Repo
rt
Whi
te-p
aper
repo
rt o
n la
rge-
grou
p m
eetin
g re
sults
: ht
tp:/
/sas
kpai
n.ca
/imag
es/P
rovi
ncia
l_Pa
in_S
tak
ehol
der_
Repo
rt_M
arch
1920
15_f
inal
Map
ping
a P
ain
Stra
tegy
for S
aska
tche
wan
: fin
ding
s fro
m st
akeh
olde
r con
sulta
tions
Su
san
Tupp
er, P
T, Ph
D1,2 ,
Glen
-mar
y Ch
risto
pher
, RN
, BN
, BA3 ,
Kare
n Ju
ckes
, RN
, MN
, PhD
(stu
dent
)2,4 ,
Krist
a Ba
erg,
BSN
, BA,
MD,
BSc
Med
, FRC
PC1,
2 1.
Sas
kato
on H
ealth
Reg
ion,
2. U
nive
rsity
of S
aska
tche
wan
, 3. S
unris
e He
alth
Reg
ion,
4. R
egin
a Q
u’Ap
pelle
Hea
lth R
egio
n
Stra
tegy
Goa
l Gu
ide
deve
lopm
ent o
f sus
tain
able
pro
gram
s, tr
aini
ng, a
nd
reso
urce
s to
supp
ort a
cces
sible
, coo
rdin
ated
pai
n m
anag
emen
t se
rvic
es a
cros
s the
con
tinuu
m o
f car
e.
Cons
ulta
tion
Met
hods
and
Fin
ding
s
Sask
atch
ewan
Con
text
Pr
ovin
cial
Pop
ulat
ion
•Po
pula
tion
of 1
.14
mill
ion.
•40
% re
sides
in tw
o la
rger
urb
an c
ente
rs
•28
% re
sides
in ru
ral a
nd re
mot
e lo
catio
ns.
Curr
ent S
peci
alty
Pai
n Se
rvic
es
•Li
mite
d, p
rimar
ily u
ni-d
iscip
linar
y, cl
uste
red
in u
rban
cen
ters
.
Heal
thca
re in
Sas
katc
hew
an
•M
inist
ry o
f Hea
lth p
rovi
des o
vers
ite a
nd
stra
tegi
c di
rect
ion
to 1
3 pr
ovin
cial
hea
lth
regi
ons.
•
Min
istry
prio
ritie
s for
201
5-16
•
Men
tal h
ealth
and
add
ition
s •
Seni
ors c
are
•Ap
prop
riate
ness
of c
are
•Em
erge
ncy
depa
rtm
ent w
aits
.
Onl
ine
Surv
ey
Met
hods
Pr
imar
y ca
re p
hysic
ians
and
nur
se p
ract
ition
ers
(n=8
3; 2
4% re
spon
se ra
te) i
n th
e Sa
skat
oon
Heal
th
Regi
on.
•O
pini
ons o
f exi
stin
g se
rvic
es fo
r chr
onic
pai
n
•Pr
iorit
ies f
or n
ew p
rogr
amm
ing
•Pe
rcei
ved
barr
iers
to c
are
for c
lient
s with
ch
roni
c pa
in.
Part
icip
ants
Fi
ndin
gs
•Hi
gh p
ropo
rtio
ns u
naw
are
of o
r did
not
refe
r cl
ient
s to
avai
labl
e pa
in se
rvic
es.
•In
terv
entio
nal P
ain
Clin
ic 4
9%
•Li
veW
ell w
ith C
hron
ic P
ain
57%
•
Med
icat
ion
Asse
ssm
ent C
ente
r 79%
Pr
iorit
ies
Di
agno
stic
con
sulta
tion
serv
ice
M
ultid
iscip
linar
y tr
eatm
ent p
rogr
am
Su
ppor
t for
tran
sitio
n fr
om a
cute
car
e
M
ento
red
lear
ning
opp
ortu
nitie
s Pe
rcei
ved
Barr
iers
to C
are
Ove
rvie
w
Sa
skat
chew
an st
akeh
olde
rs w
ere
cons
ulte
d to
ide
ntify
opp
ortu
nitie
s an
d ba
rrie
rs fo
r dev
elop
men
t and
impl
emen
tatio
n of
a p
rovi
ncia
l pai
n st
rate
gy. A
ctio
nabl
e fu
ture
wor
k ha
s bee
n st
ruct
ured
aro
und
the
follo
win
g fo
ur fo
ci o
f cha
nge.
Wor
k in
Pro
gres
s •
Cons
ulta
tion
on st
rate
gy
repo
rt a
nd a
ctio
n ite
m p
lan
•
Core
pla
nnin
g gr
oup
regu
lar m
eetin
gs
Futu
re W
ork
•Id
entif
y le
ads f
or 4
wor
king
gr
oups
•
Org
anize
wor
king
gro
up
mee
tings
for
upc
omin
g pa
in c
onfe
renc
e in
Reg
ina,
N
ovem
ber 2
016.
Ackn
owle
dgem
ents
: Thi
s wor
k ha
s bee
n pr
imar
ily le
d by
The
Sas
katc
hew
an R
egist
ered
Nur
ses’
Ass
ocia
tion
(SRN
A) P
ain
Man
agem
ent P
rofe
ssio
nal P
ract
ice
Grou
p m
embe
rs. F
acili
tate
d la
rge-
grou
p m
eetin
gs w
ere
supp
orte
d by
the
SRN
A, C
olle
ge o
f Phy
sicia
ns a
nd S
urge
ons o
f Sas
katc
hew
an, a
nd th
e Ca
nadi
an P
ain
Coal
ition
. Spe
cial
than
ks to
Mar
ia H
udsp
ith, e
xecu
tive
dire
ctor
of P
ainB
C an
d Ly
nn C
oope
r, pr
esid
ent o
f the
Can
adia
n Pa
in C
oalit
ion,
fo
r pre
sent
ing
at a
nd p
artic
ipat
ing
in th
e fa
cilit
ated
gro
up m
eetin
gs.
Inte
rvie
ws a
nd F
ocus
Gro
ups
Met
hods
Pa
in-r
elat
ed n
eeds
and
ass
ets a
sses
smen
t of
Sask
atoo
n He
alth
Reg
ion.
•
Inte
rvie
ws a
nd fo
cus g
roup
s with
pat
ient
s and
fa
mili
es, m
ultid
iscip
linar
y he
alth
care
pro
vide
rs,
man
ager
s, a
nd se
rvic
e lin
e di
rect
ors.
Fi
ndin
gs
Prio
rity
gaps
: 1.
Inco
nsist
ent p
rovi
der a
ppro
ach
to p
ain
asse
ssm
ent a
nd m
anag
emen
t in
acut
e ca
re,
long
-term
car
e, a
nd p
rimar
y ca
re.
2.La
ck o
f spe
cial
ty p
ain
serv
ices
and
co
ordi
natio
n of
car
e, p
artic
ular
ly fo
r tho
se
with
com
plex
pai
n co
nditi
ons.
3.
Lack
of h
ealth
care
pro
vide
r and
clie
nt/f
amily
aw
aren
ess o
f exi
stin
g se
rvic
es.
Five
act
ion
cate
gorie
s for
futu
re im
prov
emen
t wor
k:
Faci
litat
ed L
arge
-Gro
up M
eetin
gs
Met
hods
Tw
o la
rge-
grou
p fa
cilit
ated
mee
tings
wer
e he
ld d
urin
g a
pain
con
fere
nce
in S
aska
toon
in N
ovem
ber 2
014.
Pa
rtic
ipan
ts (n
=147
) rep
rese
nted
7 h
ealth
regi
ons:
•
Clie
nt/f
amily
adv
ocat
es
•M
ultid
iscip
linar
y he
alth
care
pro
vide
rs
•He
alth
care
adm
inist
rato
rs
•N
on-g
over
nmen
tal
orga
niza
tions
•
Heal
th p
rofe
ssio
nal a
ssoc
iatio
ns
•Pr
ovin
cial
Min
istry
of H
ealth
•
Acad
emic
inst
itutio
ns
Find
ings
1.
Rese
arch
and
dat
a ne
eds
•Co
mpr
ehen
sive
need
s and
ass
ets a
sses
smen
t in
clud
ing
uniq
ue n
eeds
of F
irst N
atio
ns, I
nuit
and
Mét
is pe
ople
s.
•Ec
onom
ic re
sear
ch a
nd b
usin
ess p
lan
to g
uide
new
pr
ogra
m p
lann
ing.
2.St
ruct
ures
and
Res
ourc
e N
eeds
: •
Prov
inci
al p
ain
foun
datio
n •
Pain
edu
catio
n re
form
•
Coor
dina
ted
rese
arch
and
kno
wle
dge
tran
slatio
n th
at se
rves
clin
ical
impr
ovem
ent w
ork
•Re
gion
al c
ham
pion
s to
lead
loca
l wor
k •
Dive
rse
spec
ialty
pai
n se
rvic
es
•O
utco
me
mon
itorin
g.
3.
Proc
esse
s:
•Cl
inic
al p
athw
ay
•Ce
ntra
lized
tria
ge a
nd re
ferr
al co
ordi
natio
n •
Lim
it ru
ral d
ispar
ities
•
Colla
bora
tion
betw
een
heal
th re
gion
s.
Cha
ract
eris
tics
Year
s of
pra
ctic
eM
edia
n 11
-15
year
sP
opul
atio
n se
rved
:
I
nner
city
14%
Urb
an57
%S
mal
lto
mid
-siz
ed to
wns
12%
Rur
al a
nd re
mot
e12
%G
roup
pra
ctic
e72
%P
ract
ice
setti
ng:
Priv
ate
offic
e51
%P
rimar
y he
alth
cen
ter
36%
Pai
nfo
unda
tion
Inte
r-pr
ofes
sion
al
educ
atio
n
Res
earc
h an
dkn
owle
dge
trans
latio
n
Pra
ctic
e an
d pr
ogra
m
deve
lopm
ent
Pai
nfo
unda
tion
Inte
r-pr
ofes
sion
al
educ
atio
n
Res
earc
h an
dkn
owle
dge
trans
latio
n
Pra
ctic
e an
d pr
ogra
m
deve
lopm
ent
ww
w.sa
skat
chew
an.c
a
3o 2o 1o
Pre
vent
ion
and
Ear
ly In
terv
entio
n
Cont
act:
susa
n.tu
pper
@us
ask.
ca
29
Tem
plat
e ID
: ste
pbys
tepc
ircle
s S
ize:
a0
Deve
lopm
ent o
f a b
rief e
duca
tion
serie
s for
hea
lthca
re p
rovi
ders
: U
nder
stan
ding
, Ass
essi
ng a
nd M
anag
ing
Pain
in O
lder
Adu
lts
Tupp
er S
M1,
2 , Ba
reha
m J3 ,
Dany
lysh
en-L
ayco
ck T
1,2 ,
Berg
en A
2 1.
Uni
vers
ity o
f Sas
katc
hew
an, 2
. Sas
kato
on H
ealth
Reg
ion,
3. R
xFile
s – L
ong
Term
Car
e Pr
ojec
t
Clie
nts
Clin
icia
nsC
lient
sVe
rsio
n 11
Clie
nts
1.M
isco
ncep
tions
abo
ut p
ain
in
olde
radu
lts2.
Type
sof
pai
n3.
The
lang
uage
of p
ain
4.P
ain
asse
ssm
ent o
verv
iew
5.S
elf r
epor
t of p
ain
6.B
ehav
iora
l pai
n as
sess
men
t7.
4 P
’s o
f pai
n m
anag
emen
t
8.P
rinci
ples
of p
harm
aceu
tical
tre
atm
ent
9.M
edic
atio
ns fo
r noc
icep
tive
pain
10.M
edic
atio
ns fo
r neu
ropa
thic
pai
n11
.Phy
sica
ltre
atm
ent s
trate
gies
12.P
sych
olog
ical
treat
men
t stra
tegi
es13
.Pre
vent
ion
stra
tegi
es
INTR
OD
UC
TIO
NP
ain
in o
lder
adu
lts is
ofte
n un
der-
reco
gniz
ed, i
ncor
rect
ly a
sses
sed,
and
un
der-
man
aged
[1].
The
maj
ority
of o
lder
adu
lts li
ve w
ith p
ain
on a
regu
lar
basi
s, w
ith re
porte
dra
tes
of c
hron
ic p
ain
of60
-80%
am
ong
thos
e liv
ing
in
resi
dent
ial c
are
[2].
Pai
n in
terfe
res
with
phy
sica
l and
cog
nitiv
e fu
nctio
n, a
nd
cont
ribut
es to
loss
of i
ndep
ende
nce
[2].
In p
art p
ain
unde
r-man
agem
ent
stem
s fro
m m
isco
ncep
tions
abo
ut p
ain
and
chal
leng
es w
ith a
sses
smen
t and
m
anag
emen
t of p
ain,
par
ticul
arly
for t
hose
with
dem
entia
or o
ther
cog
nitiv
e or
co
mm
unic
atio
n im
pairm
ents
[3].
On
aver
age,
clin
icia
ns h
ave
low
kno
wle
dge
and
conf
iden
ce to
ass
ess
and
prov
ide
pain
man
agem
ent i
n th
is p
opul
atio
n [4
]. Th
ere
was
a n
eed
for p
ain
educ
atio
n op
portu
nitie
s th
at c
ould
be
read
ily
impl
emen
ted
at th
e po
int-o
f-car
e th
at c
ould
be
used
to re
min
d st
aff a
bout
bes
t pr
actic
e fo
r pai
n as
sess
men
t and
man
agem
ent.
PUR
POSE
We
deve
lope
d a
serie
s of
13
brie
f edu
catio
n vi
deos
for s
taff
on d
iffer
ent
aspe
cts
of p
ain.
We
will
eva
luat
e th
e im
pact
of t
he v
ideo
s on
sta
ff kn
owle
dge
and
conf
iden
ce to
pro
vide
car
e fo
r the
old
er a
dult
popu
latio
n.
VID
EO F
OR
MAT
Vide
os ra
nge
in le
ngth
from
5 to
10
min
utes
, and
con
sist
of n
arra
tion
or v
ideo
de
mon
stra
tions
of s
kills
. Vid
eos
will
be
publ
icly
ava
ilabl
e on
You
Tube
. The
re
are
3 qu
iz q
uest
ions
at t
he e
nd o
f eac
h vi
deo
to te
st v
iew
ers’
kno
wle
dge.
Li
nks
to re
fere
nces
and
add
ition
al re
sour
ces
are
prov
ided
.
REF
EREN
CES
1.H
err K
.Pai
n in
the
olde
r adu
lt: a
n im
pera
tive
acro
ss a
ll he
alth
car
e se
tting
s. P
ain
Man
agN
urs
2010
;11(
2 S
uppl
): S
1-10
.2.
Pat
el K
V e
t al.
Pre
vale
nce
and
impa
ct o
f pai
n am
ong
olde
r adu
lts in
the
Uni
ted
Sta
tes:
find
ings
from
the
2011
Nat
iona
l Hea
lth a
nd A
ging
Tre
nds
Stu
dy. P
ain
2013
;154
(12)
: doi
:10.
1016
.3.
Had
jista
vrop
oulo
s T
et a
l. Tr
ansf
orm
ing
long
-term
car
e pa
in m
anag
emen
t in
Nor
th
Am
eric
a: th
e po
licy-
clin
ical
inte
rface
. Pai
n M
ed. 2
009;
10(3
):506
-520
.4.
Bur
ns M
& M
cIlfa
trick
S. P
allia
tive
care
in d
emen
tia: l
itera
ture
revi
ew o
f nur
ses’
kn
owle
dge
and
attit
udes
tow
ards
pai
n as
sess
men
t. In
tJP
allia
tNur
s.20
15;2
1(8)
:400
-407
.
VID
EO D
EVEL
OPM
ENT
PRO
CES
SA
core
dev
elop
men
t tea
m c
onsi
stin
g of
a p
hysi
cal
ther
apis
t and
pai
n co
nsul
tant
(ST)
, beh
avio
ral
cons
ulta
nt a
nd s
ocia
l wor
ker (
TDL)
, nur
se a
nd
man
ager
of S
enio
rs’ H
ealth
and
Con
tinui
ng C
are
(AB
), an
d ph
arm
acis
t an
d ac
adem
ic d
etai
ler (
JB) h
eld
regu
lar m
eetin
gs
betw
een
Apr
il 20
14 a
nd O
ctob
er 2
015
to d
evel
op c
onte
nt fo
r the
vi
deos
bas
ed o
n be
st p
ract
ice
liter
atur
e. O
nce
a dr
aft s
crip
t was
de
velo
ped,
revi
ewer
s w
ere
aske
d to
pro
vide
feed
back
and
re
com
men
d co
nten
t cha
nges
. Rev
iew
ers
incl
uded
nur
se
educ
ator
s, a
ger
iatri
c ps
ycho
logi
st, c
lient
/fam
ily a
dvis
ors,
in
ter-
prof
essi
onal
pra
ctic
e le
ads,
a p
rofe
ssor
of p
sych
olog
y,
and
the
dire
ctor
of I
nter
prof
essi
onal
Pra
ctic
e, E
duca
tion
and
Res
earc
h.A
gran
t was
pro
vide
d by
the
RU
H
Foun
datio
n to
pro
fess
iona
lly d
evel
op th
e vi
deos
with
the
Med
ia P
rodu
ctio
n de
partm
ent a
t the
Uni
vers
ity o
f S
aska
tche
wan
. Pre
limin
ary
vide
o ed
iting
w
as c
ondu
cted
from
Jun
e to
Aug
ust 2
016.
Vi
deos
are
cur
rent
ly b
eing
re-e
dite
d an
d
fina
lized
. Com
plet
ion
is e
xpec
ted
for J
anua
ry 2
017.
deve
lope
d, re
view
ers
wer
e as
ked
to p
rovi
de fe
edba
ck a
nd
prof
essi
onal
pra
ctic
e le
ads,
a p
rofe
ssor
of p
sych
olog
y,
and
the
dire
ctor
of I
nter
prof
essi
onal
Pra
ctic
e, E
duca
tion
and
A gr
ant w
as p
rovi
ded
by th
e R
UH
Fo
unda
tion
to p
rofe
ssio
nally
dev
elop
the S
CR
IPT
EVA
LUAT
ION
PLA
NA
rand
omiz
ed c
ontro
lled
trial
will
be
used
to c
ompa
re v
iew
ers’
kn
owle
dge
and
conf
iden
ce to
pro
vide
car
e be
twee
n an
atte
ntio
n co
ntro
l an
d tw
o in
terv
entio
n ar
ms
who
wat
ch 4
of t
he v
ideo
ser
ies
(Gro
up 1
: se
ssio
ns 1
, 2, 3
, 4; G
roup
2: s
essi
ons
5, 7
, 8, 1
1). W
e w
ill re
crui
t nur
sing
st
uden
ts a
nd n
urse
s (r
egis
tere
d an
d lic
ense
d pr
actic
al n
urse
s) fr
om
acut
e ca
re fa
cilit
ies
and
long
-term
car
e ho
mes
and
com
pare
cha
nge
in
know
ledg
e us
ing
two
valid
ated
pai
n kn
owle
dge
tool
s. T
he c
ontro
l gro
up
will
be
prov
ided
link
s to
the
vide
os fo
llow
ing
the
stud
y.
VID
EOSE
SSIO
N T
ITLE
S
AC
KN
OW
LED
GEM
ENTS
We
grat
eful
ly a
ckno
wle
dge
the
gene
rous
sup
port
from
don
ors
to th
e R
UH
Fo
unda
tion
for t
he g
rant
that
sup
porte
d pr
ofes
sion
al v
ideo
dev
elop
men
t. Th
ank
you
to M
ark
Beh
rend
from
the
Med
ia P
rodu
ctio
n de
partm
ent a
t the
U
nive
rsity
of S
aska
tche
wan
, vol
unte
er a
ctor
s Jo
an C
laas
sen,
Geo
rge
Epp
, Bar
b Fr
oese
, and
Cam
eron
Nic
olle
, and
man
y re
view
ers
for t
heir
valu
able
con
tribu
tions
.
30
Stud
y 1:
Val
idat
ion
of C
AM
CI w
ith
RR
MC
pat
ient
sD
eter
min
e th
e va
lidity
and
feas
ibili
ty o
f C
AM
CI b
atte
ry w
ith ru
ral/r
emot
e pa
tient
po
pula
tion.
•R
ecru
it R
RM
C p
atie
nts
to c
ompl
ete
CAM
CI b
atte
ry.
•D
ocum
ent h
ow w
ell t
oler
ated
the
CAM
CI i
s in
this
pop
ulat
ion.
•D
ocum
ent t
he c
onve
rgen
t and
di
scrim
inan
t val
idity
of t
he C
AMC
I ba
ttery
in th
is p
opul
atio
n.
Stud
y 2:
Impl
emen
tatio
n of
rem
ote
spec
ialis
t-to-
PHC
pro
vide
r sup
port
pr
ogra
m.
Est
ablis
h a
plat
form
to re
mot
ely
adm
inis
ter C
LSA
tele
phon
e ba
ttery
and
C
AM
CI d
igita
l bat
tery
to p
atie
nts
with
su
spec
ted
cogn
itive
impa
irmen
t in
rura
l/rem
ote
area
s.•
Rur
al P
HC
pro
vide
rs w
ill in
vite
pat
ient
s to
com
plet
e C
AMC
I bat
tery
•Pa
tient
s w
ill be
con
tact
ed b
y te
leph
one
and
adm
inis
tere
d C
LSA
batte
ry•
Test
resu
lts w
ill be
inte
rpre
ted
for P
HC
pr
ovid
ers.
Intr
od
uct
ion
Purp
ose
Impr
ove
timel
y di
agno
sis
of p
atie
nts
with
dem
entia
in ru
ral/r
emot
e ar
eas
by
deve
lopi
ng, i
mpl
emen
ting,
and
ev
alua
ting
a te
chno
logy
-bas
ed p
latfo
rm
that
con
nect
s ur
ban
dem
entia
sp
ecia
lists
with
rura
l prim
ary
heal
thca
re
(PH
C) p
rovi
ders
.
Rat
iona
le•
564,
000
Can
adia
ns li
ve w
ith d
emen
tia, p
laci
ng a
si
gnifi
cant
bur
den
on in
form
al c
areg
iver
s, a
nd
cost
ing
Can
adia
ns $
10.4
billi
on a
nnua
lly.1
•Ti
mel
y di
agno
sis
impr
oves
pat
ient
qua
lity
of li
fe2 ,
whi
le la
te d
iagn
osis
is a
ssoc
iate
d w
ith
hosp
italiz
atio
n an
d pr
emat
ure
long
-term
car
e pl
acem
ent.3
,4
•La
ck o
f ava
ilabi
lity
of s
peci
alis
ts a
nd re
sour
ces
in
rura
l are
as le
aves
bur
den
of d
iagn
osis
on
prim
ary
heal
thca
re (P
HC
) pro
vide
rs, w
ho o
ften
lack
de
men
tia-s
peci
fic tr
aini
ng.5
•G
eogr
aphi
c, fi
nanc
ial,
and
time
issu
es m
ay
proh
ibit
rura
l pat
ient
s fro
m s
eeki
ng c
are
in u
rban
ce
nter
s.6
•Pr
elim
inar
y re
sear
ch s
ugge
sts
tele
heal
th
neur
opsy
chol
ogic
al a
sses
smen
ts a
re v
alid
and
w
ell-t
oler
ated
, and
may
hav
e di
agno
stic
util
ity.5
•C
anad
ian
Long
itudi
nal S
tudy
on
Agin
g (C
LSA)
de
velo
ped
and
gath
ered
nor
mat
ive
data
on
a te
leph
one-
adm
inis
tere
d ne
urop
sych
olog
ical
in
stru
men
t.•
Com
pute
r Ass
iste
d M
ild C
ogni
tive
Impa
irmen
t (C
AMC
I) is
a re
liabl
e an
d va
lid a
utom
ated
co
gniti
ve a
sses
smen
t ins
trum
ent6
whi
ch m
ay
influ
ence
PH
C p
rovi
der’s
car
e de
cisi
ons.
7
Impr
ovin
g ru
ral d
emen
tia d
iagn
osis
: Im
plem
entin
g re
mot
e sp
ecia
list-t
o-PH
C p
rovi
der s
uppo
rt Pro
po
sed
Res
earc
h
J. U
rsen
bach
1&
M. E
. O’C
onne
ll11 D
epar
tmen
t of P
sych
olog
y, U
nive
rsity
of S
aska
tche
wan
1 Alz
heim
er’s
Soc
iety
of C
anad
a. (2
016)
. Dem
entia
num
bers
in C
anad
a. R
etrie
ved
Oct
ober
10,
201
6, fr
om h
ttp://
ww
w.a
lzhe
imer
.ca/
en/A
bout
-dem
entia
/Wha
t-is-
dem
entia
/Dem
entia
-num
bers
2 Alz
heim
er’s
Dis
ease
Inte
rnat
iona
l. W
orld
Alz
heim
er R
epor
t 201
1. L
ondo
n.3 G
augl
erJ
et a
l. (2
005)
. Ear
ly c
omm
unity
-bas
ed s
ervi
ce u
tiliz
atio
n &
its e
ffect
s on
inst
itutio
naliz
atio
n in
dem
entia
car
egiv
ing.
Ger
onto
logi
st, 4
5, 1
77-8
5.4 M
cClo
skey
R e
t al.
(201
4). A
ltern
ate
leve
l of c
are
patie
nts
in h
ospi
tals
. Jou
rnal
of C
anad
ian
Ger
iatri
cs,1
7, 8
8-94
.5 M
orga
n, D
., In
nes,
A. &
Kos
teni
uk, J
. (20
11).
Dem
entia
car
e in
rura
l and
rem
ote
setti
ngs:
A s
yste
mat
ic re
view
of f
orm
al o
r pai
d ca
re. M
atur
itas,
68,
17-
33.
6 For
bes,
D.,
Mor
gan,
D. &
Jan
zen,
B. (
2006
). R
ural
and
urb
an C
anad
ians
with
dem
entia
: Use
of h
ealth
car
e se
rvic
es. C
anad
ian
Jour
nal o
n Ag
ing,
25(
3), 3
21-3
30.
6 Tie
rney
, M. C
. et a
l. (2
016)
. Fea
sibi
lity
and
Valid
ity o
f the
Sel
f-adm
inis
tere
d C
ompu
teriz
ed A
sses
smen
t of M
ild C
ogni
tive
Impa
irmen
t With
Old
er P
rimar
y C
are
Patie
nts.
Alz
heim
er’s
Dis
ease
and
Ass
ocia
ted
Dis
orde
rs, 0
(0),
1-9.
7 Tie
rney
, M. C
. et a
l. (2
016)
. The
Effe
cts
of C
ompu
teriz
ed C
ogni
tive
Test
ing
of O
lder
Pat
ient
s on
Prim
ary
Car
e Ph
ysic
ians
’ App
roac
hes
to C
are.
Alz
heim
er’s
Dis
ease
and
Ass
ocia
ted
Dis
orde
rs, 0
(0),
1-7.
Pro
po
sed
Res
earc
h
RR
MC
Fun
ding
and
in-k
ind
supp
ort i
s ge
nero
usly
pro
vide
d by
:
Imp
lica
tio
ns
•R
emot
e sp
ecia
list-t
o-PH
C p
rovi
der
supp
ort w
ill im
prov
e di
agno
sis
of
dem
entia
in ru
ral a
reas
.•
Early
dia
gnos
is re
duce
s nu
mbe
r of r
ural
de
men
tia p
atie
nts
that
ent
er lo
ng-te
rm
care
pre
mat
urel
y, s
avin
g as
soci
ated
co
sts.
•Im
prov
e qu
ality
of l
ife o
f inf
orm
al
care
give
rs, w
ho u
se d
iagn
ostic
in
form
atio
n to
tap
appr
opria
te re
sour
ces
and
prog
nost
ic in
form
atio
n to
pla
n ac
cord
ingl
y.
Stud
y 3:
Eva
luat
ion
of C
AM
CI a
nd
CLS
A fe
edba
ck o
n PH
C p
rovi
ders
’ tr
eatm
ent d
ecis
ions
Det
erm
ine
exte
nt to
whi
ch re
mot
e sp
ecia
list-t
o-P
HC
pro
vide
r pla
tform
in
fluen
ced
deliv
ery
of h
ealth
care
.•
Rev
iew
ele
ctro
nic
med
ical
reco
rds
(EM
R) o
f pat
ient
s in
Stu
dy 2
.•
Cod
e tre
atm
ent d
ecis
ions
influ
ence
d by
C
AMC
I or C
LSA
resu
lts.
•In
terv
iew
PH
C p
rovi
ders
; qua
litat
ive
anal
ysis
of r
espo
nses
.
Thes
e re
sear
ch p
rogr
ams
wor
k be
st w
hen
we
wor
k to
geth
er. W
e w
ould
love
to h
ear y
our t
houg
hts!
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31
TEM
PLAT
E D
ESIG
N ©
200
8
ww
w.P
oste
rPre
sent
atio
ns.c
om
Figu
re 3
: Cha
nge
in M
DTL
nor
mal
app
earin
g W
M A
SMov
er 3
yea
rs;
mar
gina
lly s
igni
fican
t bila
tera
l inc
reas
e fro
m B
L to
3Y.
Poi
nts
repr
esen
t es
timat
ed m
argi
nal m
eans
whe
n co
ntro
lling
for a
ge; e
rror b
ars
repr
esen
t st
anda
rd e
rror o
f the
est
imat
e.
Pred
ictin
g co
gniti
ve d
eclin
e af
ter T
IA w
ith d
iffus
ion
tens
or im
agin
g an
d te
xtur
e an
alys
is o
f nor
mal
app
earin
g w
hite
mat
ter
Urs
enba
ch, J
.1,2 ,
Cam
peau
, S.1,
2 , Ta
riq, S
.1,2 ,
Car
lson
, H.L
.3,4,
5 , C
outts
, S.1,
6&
Barb
er P
.A.1,
61 C
alga
ry S
troke
Pro
gram
, Dep
artm
ent o
f Clin
ical
Neu
rosc
ienc
es, U
nive
rsity
of C
alga
ry, 2 S
eam
an F
amily
MR
Cen
ter,
3 Alb
erta
Chi
ldre
n’s
Hos
pita
l Res
earc
h In
stitu
te, 4 C
alga
ry
Pedi
atric
Stro
ke P
rogr
am, 5 D
epar
tmen
ts o
f Ped
iatri
cs a
nd C
linic
al N
euro
scie
nces
, Uni
vers
ity o
f Cal
gary
, 6 Hot
chki
ss B
rain
Inst
itute
Intr
oduc
tion
-Pat
ient
s w
ith tr
ansi
ent i
sche
mic
atta
ck (T
IA) h
ave
an e
leva
ted
risk
of re
curre
nt s
troke
s, c
ogni
tive
decl
ine,
and
neu
rode
gene
rativ
e di
sord
ers,
incl
udin
g a
4-fo
ld ri
sk o
f dev
elop
ing
dem
entia
late
r in
life.
1
-Thi
s pr
ovid
es a
pop
ulat
ion
for i
dent
ifyin
g bi
omar
kers
of i
ncip
ient
dis
ease
pro
cess
es.
-Fra
ctio
nal a
niso
troph
y (F
A), a
diff
usio
n te
nsor
im
agin
g (D
TI) d
eriv
ed p
aram
eter
, det
ects
cha
nges
in
whi
te m
atte
r (W
M) i
nteg
rity
evid
ent i
n pa
tient
s w
ith
Alzh
eim
er’s
dis
ease
(AD
) and
vas
cula
r dem
entia
2 .-G
rey
leve
l co-
occu
rrenc
e m
atrix
(GLC
M) b
ased
te
xtur
e an
alys
is (T
A) o
f WM
in T
1 w
eigh
ted
MR
im
ages
dis
tingu
ishe
s pa
tient
s w
ith A
D fr
om h
ealth
y co
ntro
ls3 .
-Med
ial t
empo
ral l
obes
(MD
TL) a
re im
plic
ated
in
cogn
itive
pro
cess
es s
uch
as e
piso
dic
mem
ory.
Hyp
othe
sis:
long
itudi
nal c
hang
es in
GLC
M a
nd F
A pa
ram
eter
s in
MD
TL w
ill be
ass
ocia
ted
with
a d
eclin
e in
epi
sodi
c m
emor
y in
TIA
pat
ient
s.
Met
hods
Res
ults
Dis
cuss
ion
Ref
eren
ces
-Dec
line
in F
A in
dica
tes
loss
of W
M in
tegr
ity in
the
left
MD
TL in
the
thre
e ye
ars
follo
win
g TI
A2 .-M
ay b
e m
arke
r of i
ncip
ient
dis
ease
pro
cess
.-I
nter
pret
atio
n su
ppor
ted
by e
vide
nce
that
dec
linin
g FA
val
ues
are
asso
ciat
ed w
ith p
oore
r cog
nitiv
e pe
rform
ance
in ta
sks
of e
xecu
tive
func
tion,
ver
bal
lear
ning
, vis
uosp
atia
l fun
ctio
n, a
nd e
piso
dic
mem
ory.
-Ris
ing
ASM
val
ues
indi
cativ
e of
incr
easi
ng te
xtur
e ho
mog
enei
ty; m
argi
nally
sig
nific
ant i
ncre
ase
coul
d be
evi
denc
e of
vas
cula
r rec
over
y af
ter T
IA7 .
-Stu
dy li
mite
d by
use
of t
he s
ame
cogn
itive
bat
tery
at
eac
h as
sess
men
t, le
adin
g m
any
parti
cipa
nts
to
dem
onst
rate
pra
ctic
e ef
fect
s (im
prov
emen
t ove
r tim
e). S
uch
effe
cts
may
mas
k ch
ange
in c
ogni
tive
abilit
y.-N
o co
ntro
l gro
up li
mits
und
erst
andi
ng o
f nat
ural
va
riatio
n in
MR
I and
cog
nitiv
e m
easu
res.
1 Pend
lebu
ry, S
T., e
t al.
Long
-term
risk
of d
emen
tia a
fter T
IA a
nd s
troke
: Cur
rent
est
imat
es fr
om
a la
rge
popu
latio
n-ba
sed
stud
y. C
ereb
rova
scul
ar D
isea
ses.
201
3;35
:187
-187
.2 Su
giha
ra, S
., et
al.
Use
fuln
ess
of d
iffus
ion
tens
or im
agin
g of
whi
te m
atte
r in
alzh
eim
er d
isea
se a
nd v
ascu
lar d
emen
tia. A
cta
Rad
iolo
gica
. 200
4;6:
658-
663.
3 Oliv
iera
, M.,
et a
l. M
R Im
agin
g Te
xtur
e An
alys
is o
f the
Cor
pus
Cal
losu
m a
nd T
hala
mus
in A
mne
stic
Mild
Cog
nitiv
e Im
pairm
ent a
nd M
ild A
lzhe
imer
Dis
ease
. Am
eric
an J
ourn
al o
f Neu
rora
diol
ogy.
201
1;32
;60-
66.
4 Grie
ve, S
., et
al.
Cog
nitiv
e ag
ing,
exe
cutiv
e fu
nctio
n, a
nd fr
actio
nal a
niso
tropy
: a d
iffus
ion
tens
or M
R im
agin
g st
udy.
Am
eric
an J
ourn
al o
f Neu
rora
diol
ogy.
200
7;28
(2):2
26-2
35.
5 Koch
unov
, P.,
et a
l. R
elat
ions
hip
betw
een
whi
te m
atte
r fra
ctio
nal a
niso
tropy
and
oth
er in
dice
s of
ce
rebr
al h
ealth
in n
orm
al a
ging
: Tra
ct-b
ased
spa
tial s
tatis
tics
stud
y of
agi
ng. N
euro
Imag
e.
2007
;35(
2);4
78-4
87.
6 Hw
ang,
J. e
t al.
Text
ure
anal
yses
of q
uant
itativ
e su
scep
tibilit
y m
aps
to d
iffer
entia
te A
lzhe
imer
’s
dise
ase
from
cog
nitiv
e no
rmal
and
mild
cog
nitiv
e im
pairm
ent.
2016
;43(
8);4
718-
4728
.7 M
ahaj
an, A
. et a
l. D
etec
ting
Dis
ease
d Ti
ssue
in N
orm
al A
ppea
ring
Whi
te M
atte
r of T
rans
ient
Is
chem
ic A
ttack
and
Min
or S
troke
Pat
ient
s U
sing
Tex
ture
Ana
lysi
s. IS
C In
tern
atio
nal S
troke
C
onfe
renc
e 20
15;T
MP1
17.
-86
TIA/
min
or s
troke
pat
ient
s w
ere
recr
uite
d ac
utel
y fro
m E
xten
ded
CAT
CH
stu
dy.
-DTI
acq
uire
d us
ing
14 n
on-c
ollin
ear d
iffus
ion
enco
ded
scan
ning
dire
ctio
ns w
ith a
slic
e th
ickn
ess
of
3.5m
m.
-FLA
IR im
ages
wer
e ac
quire
d w
ith a
slic
e th
ickn
ess
of 3
.5m
m.
-Ser
ial M
R im
agin
g at
48H
, 18M
, 3Y;
ser
ial c
ogni
tive
asse
ssm
ents
at 9
0D, 1
Y, 2
Y, 3
Y.•W
AIS-
IV D
igit
Sym
bol C
odin
g: p
sych
omot
or
proc
essi
ng s
peed
•Tra
il M
akin
g Te
st P
art B
: Exe
cutiv
e fu
nctio
n•C
ontro
lled
Ora
l Wor
d As
soci
atio
n Ta
sk: S
peed
ed
lexi
cal f
luen
cy a
nd la
ngua
ge fu
nctio
n•C
alifo
rnia
Ver
bal L
earn
ing
Test
: Ver
bal l
earn
ing
and
epis
odic
mem
ory.
•Rey
-Ost
errie
th C
ompl
ex F
igur
e Ta
sk: E
piso
dic
mem
ory
and
visu
ospa
tial f
unct
ion.
-DTI
and
T2-
wei
ghte
d FL
AIR
imag
es p
repr
oces
sed
with
Fre
esur
fer &
FM
RIB
sof
twar
e lib
rary
(FSL
).
-Reg
ions
of i
nter
est w
ere
draw
n bi
late
rally
in
norm
al a
ppea
ring
WM
in M
DTL
(Fig
ure
1A).
-GLC
M p
aram
eter
ang
ular
sec
ond
mom
ent (
ASM
) us
ed to
qua
ntify
text
ure
hom
ogen
eity
in T
2 FL
AIR
im
age;
com
pute
d vi
a G
LCM
text
ure
anal
ysis
util
ity
in Im
ageJ
(Fig
ure
1B).
-Ran
dom
inte
rcep
t lin
ear m
ixed
effe
cts
regr
essi
on
(LM
ER) m
odel
s w
ere
used
to m
odel
cha
nge
in F
A an
d AS
M; a
ge in
clud
ed a
s co
varia
te to
con
trol f
or
natu
ral a
ge-re
late
d de
clin
e do
cum
ente
d in
FA4 , a
nd
susp
ecte
d in
ASM
.
Figu
re 1
B: E
xam
ple
of g
ray
leve
l va
riatio
n in
T2
FLAI
R im
age
quan
tifie
d by
ASM
par
amet
er.
Figu
re 1
A: R
OIs
dra
wn
bila
tera
lly in
no
rmal
app
earin
g W
M in
the
MD
TL
Figu
re 2
: Cha
nge
in M
DTL
nor
mal
app
earin
g W
M F
Aov
er 3
yea
rs; M
DTL
le
ft si
gnifi
cant
ly d
eclin
ed fr
om B
L to
Y2,
and
BL
to Y
3; M
DTL
righ
t mar
gina
lly
decl
ined
form
BL
to Y
3.*
Tabl
e: R
esul
ts o
f lin
ear m
ixed
effe
cts
regr
essi
on m
odel
s pr
edic
ting
cogn
itive
sco
res
with
bila
tera
l FA
and
ASM
par
amet
ers
whi
le c
ontro
lling
for t
ime
and
age.
Low
er F
A va
lues
in th
e M
DTL
left
corre
spon
d to
poo
rer
perfo
rman
ce o
n ta
sks
of e
xecu
tive
func
tion,
vis
uosp
atia
l fun
ctio
n, v
erba
l le
arni
ng, a
nd e
piso
dic
mem
ory.
-Sig
nific
ant d
eclin
e in
MD
TL L
eft F
A af
ter c
ontro
lling
for a
ge (F
igur
e 2)
:•B
asel
ine
to 2
Y, t(
155.
9) =
-3.4
4, p
< .0
01•B
asel
ine
to 3
Y, t(
157.
3) =
-3.6
8, p
< .0
01-M
argi
nally
sig
nific
ant d
eclin
e in
MD
TL ri
ght F
A at
3Y
: •Bas
elin
e to
3Y,
t(15
6.2)
= -1
.76,
p <
.080
-Dec
line
in F
A du
e to
gre
ater
wat
er d
iffus
ion
perp
endi
cula
r to
whi
te m
atte
r tra
cts,
con
side
red
to
be d
ue to
dem
yelin
atio
n5 .-M
argi
nally
sig
nific
ant i
ncre
ase
in b
ilate
ral M
DTL
AS
M (F
igur
e 3)
:•L
eft:
Base
line
to 3
Y, t(
162.
6) =
1.7
3, p
= .0
86•R
ight
: Bas
elin
e to
3Y,
t(16
3.8)
= 1
.72,
p =
.087
-Ele
vate
d AS
M v
alue
s in
WM
in T
1 w
eigh
ted
imag
es d
istin
guis
h Al
zhei
mer
’s p
atie
nts
from
hea
lthy
cont
rols
6 .-F
urth
er L
MER
mod
els
wer
e us
ed to
mod
el th
e re
latio
nshi
p be
twee
n FA
and
ASM
with
cog
nitiv
e fu
nctio
n; a
ll m
odel
s w
ere
fit w
ith a
rand
om in
terc
ept
and
bila
tera
l FA
and
ASM
par
amet
ers
as w
ell a
s tim
e an
d ag
e as
cov
aria
tes
(Tab
le).
MD
TL F
A Le
ftM
DTL
FA
Rig
ht
MD
TL A
SM
Left
MD
TL A
SM
Rig
htD
igit
Sym
bol
Cod
ing
t(299
.3) =
1.
80,
p =
.072
t(239
.1) =
0.
66,
p =
.510
t(280
.4) =
-0.
18,
p =
.860
t(239
.9) =
-.6
2,p
= .5
34
Trai
l M
akin
g Te
st P
art B
t(282
.4) =
-2.
48,
p =
.014
t(262
.3) =
0.
63,
p =
.528
t(226
.7) =
0.
62,
p =
.536
t(263
.95)
= -
2.15
,p
= .0
33
Con
trol
led
Ora
l Wor
d As
soci
atio
n Te
st
t(289
.6) =
-0.
62,
p =
.537
t(261
.4) =
0.
59,
p =
.555
t(238
.1) =
1.
11,
p =
.268
t(263
.5) =
0.
38,
p =
.704
Cal
iforn
ia
Verb
al
Lear
ning
Te
st
t(265
.0) =
2.
08,
p =
.039
t(271
.8) =
0.
36,
p =
.722
t(205
.2) =
0.
08,
p =
.930
t(274
.3) =
0.
73,
p =
.464
Rey
-O
ster
rieth
C
ompl
ex
Figu
re T
est
t(186
.5) =
3.
09,
p =
.002
t(299
.2) =
0.
22,
p =
.827
t(139
.8) =
0.
35,
p =
0.72
4
t(301
.2) =
0.
13,
p =
.899
Con
clus
ions
-FA
of th
e le
ft M
DTL
nor
mal
app
earin
g w
hite
mat
ter
may
be
a ro
bust
bio
mar
ker o
f cog
nitiv
e de
clin
e af
ter
TIA,
how
ever
futu
re re
sear
ch n
eede
d to
del
inea
te
etio
logy
of c
hang
e (ie
. vas
cula
r vs.
ne
urod
egen
erat
ive
dise
ase
proc
esse
s)-A
SM w
as n
ot a
robu
st p
redi
ctor
of c
ogni
tive
func
tion
in th
is s
tudy
, how
ever
futu
re re
sear
ch to
det
erm
ine
optim
al im
age
reso
lutio
n an
d G
LCM
ste
p si
ze m
ay
impr
ove
pred
ictio
n. Ack
now
ledg
emen
tsTh
e au
thor
s w
ould
like
to th
ank
the
Hea
rt an
d St
roke
Foun
datio
n fo
r the
fund
ing.
Cor
resp
onde
nce:
urs
enba
c@uc
alga
ry.c
a or
pab
arbe
r@uc
alga
ry.c
a
MD
TL F
A Le
ftM
DTL
FA
Rig
ht
MD
TL A
SM
Left
MD
TL A
SM
Rig
ht
Dig
it Sy
mbo
l C
odin
gt(2
99.3
) = 1
.80,
p
= .0
72t(2
39.1
) = 0
.66,
p =
.510
t(280
.4) =
-0.1
8,p
= .8
60t(2
39.9
) = -.
62,
p =
.534
Trai
l Mak
ing
Test
Par
t Bt(2
82.4
) = -2
.48,
p
= .0
14t(2
62.3
) = 0
.63,
p =
.528
t(226
.7) =
0.6
2,p
= .5
36t(2
63.9
5) =
-2.1
5,p
= .0
33
Con
trolle
d O
ral W
ord
Asso
ciat
ion
Test
t(289
.6) =
-0.6
2,p
= .5
37t(2
61.4
) = 0
.59,
p =
.555
t(238
.1) =
1.1
1,p
= .2
68t(2
63.5
) = 0
.38,
p =
.704
Cal
iforn
ia
Verb
al
Lear
ning
Te
st
t(265
.0) =
2.0
8,
p =
.039
t(271
.8) =
0.3
6,p
= .7
22t(2
05.2
) = 0
.08,
p =
.930
t(274
.3) =
0.7
3,p
= .4
64
Rey
-O
ster
rieth
C
ompl
ex
Figu
re T
est
t(186
.5) =
3.0
9,
p =
.002
t(299
.2) =
0.2
2,p
= .8
27t(1
39.8
) = 0
.35,
p =
0.72
4t(3
01.2
) = 0
.13,
p =
.899
32
Created by Peter Dow
ning
–Ed
ucational M
edia Access a
nd Produ
ction © 2011
Astheprevalence
ofdementia
continuesto
increase
sodoes
thenumberof
patientspresenting
totheirprimary
care
physicians
with
mem
ory
complaints
(1).
With
people
increasingly
aware
ofdementia,a
new
trend
hasbeen
developing
inmem
oryclinics:the“w
orriedwell”
(2).This
referstopatientswho
areworriedthey
have
dementia,butare
infactneurologicallynormal(2).
Mem
oryconcerns
from
patientsaresubjective,
andmay
beinfluencedby
thepsychologicandenvironm
entalfactors,like
exposure
todementia
(3).TheMEM
Self-RatingMem
ory
Score
isused
toevaluate
patient’s
perceived
mem
ory
concerns,and
therefore
provide
insightinto
subjective
cognitive
impairm
ent.
RepeatMMSE
scores
can
bean
important
partof
evaluatingtrendsin
cognitive
ability
over
time(7).Aside
fromSC
I,otherriskfactorsford
ementia
may
includelowereducationlevels,sleep
concerns,and
psychiatric
illness
(8-11).D
epressionhasalso
been
implicated
asarisk
factor
formem
oryconcerns,as
patientswith
mild
cognitive
impairm
entwho
also
have
dementia
aretwiceas
likelyto
developAlzheimer’sdisease(11).T
heCES
-Disascreening
tool
used
toevaluate
depression,an
important
pieceof
informationtohave
inmem
orypatients(12).
Theobjectiveof
thepresentstudyisto
identifyfeatures
of“w
orriedwell”patientstobetteridentify
thosemorelikelyto
becognitively
normal.Itmay
bethat
bybetteridentifying
thoseatlower
riskof
having
dementia
orneurologicdisease
we
can
betterprioritize
specialistreferrals
and
patient
resources(2,14).T
hisisaparticularchallengein
ruralareas
(14).
Introd
uctio
n
375consecutivepatientsseen
ataruralandremotemem
ory
clinicbetweenMarch
2004
andOctober
2015
wereincluded
inthisanalysis.T
hedatacollected
includes:age,sex,yearsof
formaleducation,MMSE
scorefro
mtheinitialRRMCvisits,
CES
-Ddepression
scores,M
EMmem
oryself-ratingmem
ory
scale,alcoholconsumption,maritalstatus,hoursperweekof
work,
past
medical
history,
sleepconcerns,possession
ofa
driver’s
licence,and
information
onafamily
history
ofmem
oryconcerns.Wethen
categorized
patientsinto
oneof
twogroups
basedon
theirneurologic
diagnosis,
“normal”
(N=81)
or“other”(includes
allneurologicdiagnosis,N=294).
Com
parison
betweenthetwogroups
was
then
done
usinga
Chi-squared
test.
Thesecond
analysisused
thesamesetof
“normal”patients
(N=81)
andthesubgroup
ofpatientswith
adiagnosisof
Alzheimer’s
disease(N=146)fro
mthe“other”group.
The
samepatient
informationwas
isolated,andthen
re-analyzed
comparingthesetwogroups.Statistical
analysisagainused
theChi-squared
test.Ethics
approvalwas
obtained
fromour
localbiomedicalresearch
committee.
Metho
ds
375patientswho
underwentaninitialclinicalassessmentand
received
aneurologicdiagnosiswereincluded
inthisanalysis.W
hen
comparingthe“normal”group(N=81)andthe“other”group(N=294),agewassignificantlylowerinthe“normal”group(Table1).
Othersignificantdifferencesincluded
moreformaleducationinthe“normal”group,moreself-reportedalcoholconsumptioninthe
“normal”group,andhigherMMSE
scores
inthe“normal”group(Table1).Self-reportedmem
oryconcerns
(MEM
score)show
edno
differencebetweenthe“normal”groupandthe“other”group.Therewasno
statisticallysignificantrelationshipinself-reported
family
historyormem
oryconcerns
ordementia
betweenthesetwogroups.Therewasasignificantdifferencebetweenself-reported
previous
historyof
psychiatric
orpsychologicproblems,with
the“normal”groupmorefrequently
having
aprevious
diagnosisor
problem.Inassociationwith
that,the
“normal”groupalso
hadasignificantlyhigherCES
-Ddepression
screeningscore.Thefull
comparison
betweenthe“normal”and“other”groupsispresentedinTable1.
227patientsof
theprevious
375wereincluded
inthesecond
analysiswhich
comparedthesame“normal”group(N=81)
tothe
patientswho
received
adiagnosisofAlzheimer’sdisease(N=146).Thiscomparison
hadsimilardifferencesas
inthefirstanalysis.
Thefullcomparison
betweenthe“normal”and“A
lzheimer’sDisease”groupsisdetailedinTable2.
Thisdataismostly
self-reported,as
itisacquiredthroughaquestionnaireatthepatient’sinitialclinicassessment.Asaresult,all
variablesotherthanagehave
missing
values.T
henumberofvaluesforeachvariableisincluded
inthepreviouslymentionedTable
1andTable2.Breakdownofthe“other”diagnosiscan
befoundinTable3.
Results
Conclusion
With
over
20%
ofpatientsattheRRMCbeingdiagnosedas
cognitively
normal,wehave
afair
samplesize
toassess
differences.O
fthemanysignificant
differences
betweenthe
cognitively
normal
andothergroups,ageandMMSE
stand
outashighlyvaluableclinicalindicators.A
lzheimer’sdisease
classically
presentslaterin
life,andstatistically
mostof
the
“worriedwell”patientsw
ereintheirearlysixties.Therewasa
significantdifferenceinagebetweenthe“normal”or“w
orried
well”groupandboththe“other”groupandthe“A
lzheimer’s
Disease”group.
Wefoundthatthecognitivelynormalpatientstended
tohave
more
yearsof
formal
education.
Thecognitively-normal
patientswerealso
morelikelyto
beworking
part-tim
eor
more.Alcoholintake
was
also
significantlydifferentbetween
the
two
groups.The
“Alzheimer’s
Disease”
group
had
significantlylessconcerns
with
sleepthan
the“normal”group.
Subjectivemem
oryconcerns
hasbeen
show
nto
bearisk
factor
fordementia,however
ourMEM
Self
Mem
ory
Assessm
entshowed
nodifferencebetweenthe“normal”and
“other”group(12).
Itis
interestingto
note
thesignificant
differencebetween
CES
-Ddepression
screeningscores
inthe“normal”andboth
the“other”and“A
lzheimer’sDisease”groups.Itisessential
toevaluatemoodandmentalhealth
whendiscussing
mem
ory
concernswith
patients.
Overall,
webeginto
seeapattern
ofdifferences
unfold
betweenthe“w
orriedwell”patientsandthosewith
cognitive
disease.Bybetteridentifyingthe“w
orriedwell”wecanmake
betteruseof
resources,likespecialistreferrals,andimprove
patient
care
byprovidingappropriate
managem
entaimed
attheunderlyingcauseoftheconcern.
Citatio
ns1.
Cutler,S.
J.(2015).WorriesAbout
GettingAlzheimer’sWho’sConcerned?.
Amer
ican
jour
nal
ofAl
zhei
mer
'sdi
seas
ean
dot
herd
emen
tias,
30(6),591-598.
2.Menon,R
.,&Larner,A
.J.(2010).Use
ofcognitive
screeninginstrumentsinprimarycare:the
impactofnational
dementia
directives(NICE/SC
IE,N
ationalD
ementia
Strategy).
Fam
ilypr
actic
e,cm
q100.
3.Kinzer,A.,&Suhr,J.A
.(2015).Dem
entia
worryandits
relationshiptodementia
exposure,psychologicalfactors,
andsubjectivemem
oryconcerns.A
pplie
dN
euro
psyc
holo
gy:A
dult,1-9.
4.Ahm
ed,S.,Mitchell,J.,
Arnold,R.,Daw
son,K.,Nestor,P.J.,
&Hodges,J.R.(2008).Mem
orycomplaintsinmild
cognitive
impairm
ent,worriedwell,andsemantic
dementia
patients.
Alzh
eim
erD
isea
se&
Asso
ciat
edD
isor
ders,
22(3),227-235.
5.Jessen,F.,Wolfsgruber,S
.,Wiese,B
.,Bickel,H
.,Mösch,E
.,Kaduszkiewicz,H.,...&
Weyerer,S
.(2014).AD
dementia
riskinlateMCI,inearly
MCI,andinsubjectivemem
oryimpairm
ent.
Alzh
eim
er's
&D
emen
tia,1
0(1),76-
83.
6.Reisberg,B.,&
Gauthier,S.
(2008).C
urrentevidence
forsubjectivecognitive
impairm
ent(SC
I)as
thepre-mild
cognitive
impairm
ent(M
CI)stageof
subsequently
manifest
Alzheimer'sdisease.
Inte
rnat
iona
lPs
ycho
geri
atri
cs,
20(01),1-16.
7.Mitchell,
A.J.(2009).Ameta-analysisof
theaccuracy
ofthemini-m
entalstateexam
inationin
thedetectionof
dementia
andmild
cognitive
impairm
ent.
Jour
nalo
fpsy
chia
tric
rese
arch,4
3(4),411-431.
8.Ngandu,T.,von
Strauss,E.,H
elkala,E
.L.,Winblad,B
.,Nissinen,A.,Tuom
ilehto,J.,...&Kivipelto,M
.(2007).
Educationanddementia
Whatliesb
ehindtheassociation?.N
euro
logy,6
9(14),1442-1450.
9.Grace,J.B
.,Walker,M.P.,&McK
eith,I.G
.(2000).Acomparison
ofsleepprofilesinpatientsw
ithdementia
with
LewybodiesandAlzheimer'sdisease.
Inte
rnat
iona
ljou
rnal
ofge
riat
ric
psyc
hiat
ry,1
5(11),1028-1033.
10.Foley,D
.,Ancoli-Israel,S.,B
ritz,P.,&
Walsh,J.(2004).Sleepdisturbances
andchronicdiseaseinolderadults:
results
ofthe2003
NationalS
leep
FoundationSleepinAmericaSurvey.J
ourn
alof
psyc
hoso
mat
icre
sear
ch,5
6(5),
497-502.
11.M
odrego,P.J.,&Ferrández,J.(2004).D
epressioninpatientswith
mild
cognitive
impairm
entincreases
therisk
ofdeveloping
dementia
ofAlzheimertype:a
prospectivecohortstudy.
Arch
ives
ofne
urol
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61(8),1290-1293.
12.A
ndresen,E.
M.,Malmgren,J.A
.,Carter,W.B
.,&Patrick,D
.L.(1994).Screeningford
epressioninwellolder
adults:E
valuationofashortformoftheCES
-D.A
mer
ican
jour
nalo
fpre
vent
ive
med
icin
e.13.M
enon,R
.,&Larner,A
.J.(2010).Useofcognitive
screeninginstrumentsinprimarycare:the
impactofnational
dementia
directives(NICE/SC
IE,N
ationalD
ementia
Strategy).
Fam
ilypr
actic
e,cm
q100.
14.M
organ,D.G
.,Crossley,M.,Kirk
,A.,D’Arcy,C.,Stew
art,N.,Biem
,J.,...&
McBain,L.
(2009).Improving
accesstodementia
care:developmentand
evaluationofaruraland
remotemem
oryclinic.A
ging
and
Men
talH
ealth,
13(1),17-30.
15.M
organ,
D.G
.,Crossley,M.,Kirk,A
.,D’Arcy,C.,Stew
art,N.,Biem
,J.,...
McBain,
L.(2009).Improving
accesstodementia
care:developmentand
evaluationofaruraland
remotemem
oryclinic.A
ging
and
Men
talH
ealth,
13(1),17-30.
The “W
orrie
d Well”: C
haracteristic
s of the
Cog
nitiv
ely Normal Patient Presenting
to a Rural and
Rem
ote Mem
ory Clinic
Ryan
Ver
ity1
, An
drew
Kir
k2,
Chan
dim
aKa
runa
naya
ke3 ,
Deb
ra M
orga
n31
–Co
llege
of
Med
icin
e, U
nive
rsit
y of
Sas
katc
hew
an,
2 –
Div
isio
n of
Neu
rolo
gy,
Uni
vers
ity
of S
aska
tche
wan
, 3
–Ca
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For additional information contact:Debra Morgan, PhD, RNProfessorCollege of Medicine Chair, Rural Health DeliveryCanadian Centre for Health & Safety in Agriculture (CCHSA)University of Saskatchewan104 Clinic Pl, PO Box 23Saskatoon, SK S7N 2Z4
Telephone: (306) 966-7905Facsimilie: (306) 966-8799Email: [email protected]://www.ruraldementiacare.usask.ca
